Final Report Summary - PHENOTYPE (Positive health effects of the natural outdoor environment in typical populations in different regions in Europe (PHENOTYPE))
Executive Summary:
The PHENOTYPE project objectives were to:
• Investigate the interconnections between exposure to natural outdoor environments, in both rural and urban settings, and better human health and well-being and particularly;
• Identify the underlying mechanisms at work;
• Examine the effects for different population groups;
• Examine the effects of different characteristics of the natural outdoor environment;
• Cover both preventive as well as therapeutic effects of contact with the natural environment;
• Address the implications for land-use planning and green space management, specifically focusing on the integration of human health needs, and translating the research outcomes into recommendations for policy makers and guidelines for professional practitioners.
PHENOTYPE found that in general long term exposure to green space has a range of beneficial health effects including e.g. a reduction in premature mortality, cardiovascular disease and mental health problems in adults; a reduction in blood pressure in adults and pregnant women; a reduction in obesity and sedentary behaviour, an increase in birth weight, and improvement of cognitive function in children. Furthermore, we found mixed results for asthma in children, depending on the type of green space. There are indications that the lower socio-economic groups seem to benefit more, and that surrounding greenness is more beneficial than access to green spaces further away.
Also short term exposure to green space has beneficial effects including for example an improvement of mood and reduction of stress levels. Furthermore, it helps for physical rehabilitation after cardiovascular disease events.
Spending more time in the natural environment is associated with higher mental health scores, higher frequency of social contacts and more physical exercise, but the extent of this association varies by country. The perception of the natural environment is also important in the observed effects, and perceived quality characteristics of natural environments seem to influence restoration of stress. The benefits of blue space on health were less clear. In general, the exact role of amount and type of green space needed is still not fully clarified - there is an association with health outcomes and access and amount of green space, but not so much with the health determinants (physical activity, social contacts etc.). However, the health determinants do show an association with use and perception of the natural environment. Based on these results, we recommend that policy makers and professional practitioners should encourage the presence of green space but broaden their approach about the recommended size of public green space. There is no validated norm or standard for the size of public green space. Instead, PHENOTYPE has formulated nine key variables of the characteristics of public green spaces that define their attractiveness.
These key variables are: 1) Ownership; 2) Size and shape; 3) Biological characteristics; 4) Functional uses; 5) Localisation; 6) Management; 7) Community identity; 8) Climate/weather; 9) Nuisances.
These variables were validated by stakeholders in both the public and private sectors in four European countries.
Project Context and Objectives:
Background
At the start of the PHENOTYPE project in 2012, indications existed that close contact with nature brings benefits to human health and well-being, however, the mechanisms were not well understood. Also, most of the research had been conducted in the North West of Europe and USA. A more robust evidence base on links between exposure to natural outdoor environment and human health and well-being across Europe was needed, including a better understanding of the potential mechanisms. Inconsistency and variation in indicators for green or natural space had often made it difficult to compare results from different studies. Furthermore, there was a need for better integration of human health needs into land use planning and green space management in rural as well as urban areas.
Aims and objectives
The PHENOTYPE project objectives were to:
▪ Investigate the interconnections between exposure to natural outdoor environments, in both rural and urban settings, and better human health and well-being and particularly
▪ Identify the underlying mechanisms at work
▪ Examine the effects for different population groups
▪ Examine the effects of different characteristics of the natural outdoor environment
▪ Cover both preventive as well as therapeutic effects of contact with the natural environment
▪ Address the implications for land-use planning and green space management, specifically focusing on the integration of human health needs, and translating the research outcomes into recommendations for policy makers and guidelines for professional practitioners
The project used a multidisciplinary and integrated approach using the best and most efficient methods to understand the relation between exposure to the natural environment and health. It specifically addressed in-depth the potential mechanisms associated, and translate these findings into potential policies and management practices, taking into account potential regional, social and/or cultural differences. Stakeholders played an active role throughout the work.
The natural outdoor environment ranges from rural to urban settings, and the proposed work included and has evaluated:
- Green spaces (e.g. roof gardens, city parks, court yards) and “greenery” (forests, nature reserves/parks, mountains, farmland, trees, landscaping etc.)
- Blue spaces (water such as canals, ponds, creeks, rivers, beaches etc)
We examined the importance of both quantitative (e.g. amount, type, access, use) and qualitative characteristics (e.g. acoustic quality, identity, variety, safety) of the natural environment by collecting detailed data on these characteristics using a combination of methods of techniques. We focused on natural environments at different scales and distances of the home (city/town, neighbourhood, street level) and where possible also at other places where people stay (work, school, on their way to home/school, recreational). In addition, we considered actual use of the natural environment.
We explored underlying mechanisms related to:
▪ stress reduction/restorative function
▪ physical activity
▪ social interaction/social cohesion
▪ exposure to environmental hazards (noise/acoustic quality, air pollution)
Both preventative and therapeutic effects (in patients) have been considered. Outcomes of interest that were evaluated, were:
▪ general health and well-being (including medically unexplained symptoms
(MUPS))
▪ mental health/cognitive development
▪ stress/mood
▪ all cause, cardiovascular, cancer and respiratory mortality and morbidity
▪ birth outcomes
▪ obesity
▪ asthma
The project examined the effects for different population groups, including more vulnerable populations:
▪ pregnant women and/or foetus
▪ age groups (children)
▪ (lower) socio-economic status population groups
▪ ethnic minorities
▪ patients/people with specific health complaints
Comparative studies were conducted in different regions of Europe to examine any underlying regional, social and/or cultural differences related to the meanings, uses, mechanisms and health effects of the natural environment and we included the:
▪ North west (Netherlands, England)
▪ South (Spain)
▪ East (Lithuania)
Specific attention was paid to the application of knowledge to practice in close cooperation with relevant stakeholders. The implications for land-use planning and green space management have been addressed, specifically focusing on the integration of human health needs, and include an overall health impact assessment, including a conceptual framework.
Methods
Figure 1 (Annex I) summarizes the different parts of the study and the interdependencies between the different parts, namely the characterisation of the natural environment and the way it is used, examination of the underlying mechanisms in daily life settings, short and long term effects of the natural environment, and the implications for management and policy of the natural environment. In this section we will elaborate on each of these parts.
PHENOTYPE has addressed many of the shortcomings of the previous studies and has further:
▪ Produced a more robust and comparable evidence base on links between exposure to natural outdoor environment and human health and well-being;
▪ Extended the evidence base to new outcomes and vulnerable populations e.g. pregnant women and their foetus, children, chronic respiratory and cardiovascular patients, ethnic minorities and low social economic class;
▪ Examined the proposed mechanisms (physical activity, stress, social contacts, and to a lesser extent environmental risk factors) simultaneously in a large sample in various countries. This enabled us to study specific factors while adjusting for others, and thereby strengthening the interpretation of the results;
▪ Conducted comparable studies across Europe and produced evidence for North Western, Eastern and Southern Europe. This provided insights into regional, social and/or cultural differences in relation to natural space;
▪ Examined the effects of green space and also of blue space;
▪ Minimized the potential differences due to classification of natural space, by combining the use of conventional maps and data sources with remote sensing data and aerial photography and audit data, gather individual-level detailed data through of subjects living in the areas through questionnaire surveys, smartphones, and in-depth interviews and engaged stakeholders for further interpretation of data and discuss the implications of the research outcomes for planning and policy;
▪ Made classifications for the type and level of the indicators, which is important for policy makers;
▪ Examined the importance of both quantitative (amount, type, access, use) and qualitative characteristics (acoustic quality, identity, variety, safety) of the natural environment;
▪ Considered actual use of the natural environment, an often neglected but fundamental indicator in relation to exposure to natural environments.
▪ Considered the perception of the natural environment, also often neglected, but important to gain insight into what is important to people, and in how and why people use (or do not use) the natural environment.
PHENOTYPE found that in general long term exposure to green space has a range of beneficial health effects including e.g. a reduction in premature mortality, cardiovascular disease and mental health problems in adults; a reduction in blood pressure in adults and pregnant women; a reduction in obesity and sedentary behaviour, an increase in birth weight, and improvement of cognitive function in children. Furthermore, we found mixed results for asthma in children, depending on the type of green space. There are indications that the lower socio-economic groups seem to benefit more, and that surrounding greenness is more beneficial than access to green spaces further away.
Also short term exposure to green space has beneficial effects including for example an improvement of mood and reduction of stress levels. Furthermore, it helps for physical rehabilitation after cardiovascular disease events.
Spending more time in the natural environment is associated with higher mental health scores, higher frequency of social contacts and more physical exercise, but the extent of this association varies by country. The perception of the natural environment is also important in the observed effects, and perceived quality characteristics of natural environments seem to influence restoration of stress. The benefits of blue space on health were less clear. In general, the exact role of amount and type of green space needed is still not fully clarified - there is an association with health outcomes and access and amount of green space, but not so much with the health determinants (physical activity, social contacts etc.). However, the health determinants do show an association with use and perception of the natural environment.
Policy makers and professional practitioners should encourage the presence of green space but broaden their approach about the recommended size of public green space. There is no validated norm or standard for the size of public green space. Instead, PHENOTYPE has formulated nine key variables of the characteristics of public green spaces that define their attractiveness.
These key variables are:
1.) Ownership 2.) Size and shape 3.) Biological characteristics
4.) Functional uses 5.) Localisation 6.) Management
7.) Community identity 8.) Climate/weather 9.) Nuisances.
These variables were validated by stakeholders in both the public and private sectors in four European countries.
Project Results:
The PHENOTYPE project objectives were to:
▪ Investigate the interconnections between exposure to natural outdoor environments, in both rural and urban settings, and better human health and well-being and particularly;
▪ Identify the underlying mechanisms at work;
▪ Examine the effects for different population groups;
▪ Examine the effects of different characteristics of the natural outdoor environment;
▪ Cover both preventive as well as therapeutic effects of contact with the natural environment;
▪ Address the implications for land-use planning and green space management, specifically focusing on the integration of human health needs, and translating the research outcomes into recommendations for policy makers and guidelines for professional practitioners.
Methods
Figure 1 (Annex I) summarizes the different parts of the study and the interdependencies between the different parts, namely the characterisation of the natural environment and the way it is used, examination of the underlying mechanisms in daily life settings, short and long term effects of the natural environment, and the implications for management and policy of the natural environment. In this section we will elaborate on each of these parts.
WP 2 Methods:
Characterising the natural environment and the way it is used.
The research included evaluation of the natural environment, defined for the purposes of the project as:
▪ Green spaces (e.g. roof gardens, city parks, court yards) and “greenery”; forests, nature reserves/parks, mountains, farmland, trees, landscaping, etc.)
▪ Blue spaces; water such as canals, ponds, creeks, rivers, beaches etc.
Although many of these may actually not be ´´natural´´ since they have been man-made, for the purpose of the project we classify them as such.
One of the main aims of PHENOTYPE was to examine the importance of both quantitative (e.g. amount, type, access, use) and qualitative characteristics (e.g. acoustic quality, identity, variety, safety, rubbish) of the natural environment by collecting detailed data on these characteristics using a combination of methods. The focus lied on natural environments at different scales and distances from the home (city/town, neighbourhood, street level) and where possible also at other places where people stay (work, school, on their way to home/school, recreational). In addition, actual use of the natural environment was taken into consideration. To achieve the aim, a detailed assessment was conducted in four case cities (Barcelona, Spain; Doetinchem, the Netherlands; Kaunas, Lithuania; and Stoke-on-Trent, United Kingdom), with less detailed assessment in other study areas.
PHENOTYPE used conventional land use maps, remote sensing data from satellites and aerial photography, complemented by audits to derive comparable classifications of the natural environment in different countries. Collected data contributed to the characterisation of the natural environment (both quantitative and qualitative e.g. accessibility, acoustical quality, recreational activities, walkability etc). For the quantitative characterisation, PHENOTYPE made use of available land use maps such as COordination and INformation on the Environmental programme, initiated by the European Commission (CORINE) and Urban Atlas, and remote sensing and aerial photography to obtain comparable indices such as NDVI of the natural outdoor environment in different countries. Landsat Enhanced Thematic Mapper Plus (ETM+) data were applied to a classification and regression tree (CART) model to categorise land cover types for the urban areas of interest.
To collect additional qualitative information on the natural environment and on other physical and social features, systematic observations (audits) were conducted by trained researchers in selected neighbourhoods in the four case cities using the same methods. Since it was not feasible and not necessary to audit every street in a selected neighbourhood, a purposeful sample of streets was drawn, ensuring that important neighbourhood features were included. The selected neighbourhoods were divided into more or less homogeneous sub-areas by means of data/maps on land use/function of areas in combination with local knowledge of the area. Subsequently, trained auditors were asked to visit the sub-areas and observe them in a systematic way (auditing) using a paper form containing several close-ended questions. Every sub-area was visited by two auditors. For the first 1-2 areas, the auditors filled in the list together, discussing completion to reach consensus. In subsequent areas, where possible, the two auditors completed the audit independently and simultaneously. Furthermore, up to two natural environments of more than one hectare in size were selected per neighbourhood using GIS. Again following training in completion of the audit, two auditors visited the environments. For the first five areas, auditors undertook the interview together, discussing completion to reach consensus, thus maximizing consistency. In subsequent areas, where possible, two assessors completed the audit independently and simultaneously. In the absence of existing measures that met our requirements, the streetscape audit was developed for this project and the natural environment tool was adapted from an existing measure. Inter-rater reliability were estimated through derivation of Inter-rater Correlation Coefficients (ICC) and PCA used to ensure that any redundant items were removed and included items were grouped sensibly into domains, before overall quality scores was derived.
To investigate the mechanisms in relation to natural environments and health, a face-to-face questionnaire survey was conducted to collect data on around 1000 people in 30 selected neighbourhoods in each of the four case cities, and an in-depth study using “Calfit”, a smartphone-based monitor of time-location patterns and momentary states, on a subsample (n=100 in each of the four cities) of the participants of the questionnaire survey (for further detailed information, see next section on underlying mechanisms). The Calfit software ran on a Google Android operating system and as currently configured collected data on physical activity using the motion sensor and geographic location though a global positioning system (GPS), to obtain information on minutes spent and physical activity levels in different natural environments. Furthermore, in-depth interviews were conducted in 4 * 20 people who participated in the questionnaire survey and the smartphone study to investigate how and why people engage with the natural environment (green space and blue space). A qualitative methodology was used for that.
The work produced different indicators of natural space that can be used in the studies described below. We made a hierarchy of indicators with on the bottom simple measures such as NDVI that can be easily obtained in a comparable way for all the study areas and on the top detailed measures of for example green space with actually often local information on the quantity, quality and use that can only be obtained for only some areas after in-depth study. As part of the work, we examined the relationship between the simple and detailed measures to better understand how detailed information on small scale can help the interpretation of health studies conducted in larger areas with only simple measures available using existing epidemiological studies and registries (see below).
WP 2 Examining the underlying mechanism in the daily life setting
New data was collected to explore in detail and simultaneously the proposed mechanisms (physical activity, social contacts/cohesion, psychological restoration/stress reduction) underlying the relationship between the natural environment and health and well-being, in the four case cities (fig 2, Annex I). In each of these cities neighbourhoods varying in socio-economic status and in their distance to green space were selected. In these neighbourhoods the natural environment was characterised, and (as mentioned above already) we aimed for a selection of around 1000 randomly selected residents (almost 4000 in total, 18-75 years) participated in a questionnaire survey, 4 * 100 in a smartphone study, and 4 * 20 in in-depth interviews.
To optimally investigate what types of natural environments and different levels of accessibility are relevant in relation with the mechanisms that we investigated (physical activity, stress and restoration, and social interactions), and to investigate potential differences in this mechanism among different socio-economic population groups, we selected neighbourhoods with different socio-economic status (SES) and access to the natural environment. We used existing statistical or administrative units with existing statistical or administrative units that were as similar as possible with regard to variation in population size; in Stoke-on-Trent Lower Layer Super Output Areas (LSOAs), in Barcelona census areas, in Kaunas voting districts and in Doetinchem neighborhoods. Natural space and SES measures were assigned to all the units, using existing data. For natural space, Urban Atlas was used for Stoke-on-Trent, Barcelona and Kaunas. Since Urban Atlas was not available for Doetinchem, data of another Dutch database (‘Top10 nl’) was used. For SES no comparable data existed for the 4 cities. Therefore partners used their own local data. Then the units were ranked by each natural space and SES. Subsequently a selection of two neighbourhoods from each combination of top, middle and bottom tertiles of SES and quintiles of the natural space was made (approx. 2*3*5= 30 units). A few extra units were added to optimize contrast and reach a sufficient number of units to be able to recruit around a 1000 subjects in each city (30 subjects per units). Since there were no common person registries in these countries, subjects (aged between 18 and 75) were selected using different approaches. In Doetinchem and Stoke-on-Trent, addresses were sampled randomly from the BAG Registry (‘Buildings and Adresses’) 2012 and a local address registry respectively and the person with the closest birthday to the interview data was selected at each address, in Barcelona subjects were randomly selected from the person registry (empadronamiento) and in Kaunas subjects were sampled randomly from a 2006-2009 survey of randomly sampled people of the city of Kaunas. In each case there was an over selection of potential addresses or subjects to be able to interview at least a 1000 subjects (and 30 per unit) in each city. The target of a 1000 subjects per city was mostly based on the available budget. To enable multi-level analysis, we estimated that a minimum of 30 participants per group (or neighbourhood) were required, with a minimum of 30 groups.
The questionnaire survey was designed to investigate three potential mechanisms in relation to natural environments and health: via physical activity, stress and restoration and social interactions as described in the project Description of Work. In addition, questions were included about environmental worries and reactions to perceived exposures (air pollution, noise, etc). The choice of indicators was based on these three mechanisms and was achieved via an interactive process of experts within the PHENOTYPE team. As much as possible questions were derived from existing and validated indices, some tailored to the specific objectives of PHENOTYPE. The questionnaire was developed in English and was translated (and back translated) into Dutch, Spanish, Catalan, and Lithuanian. The questionnaire was developed to be applied in an oral interview of at maximum 60 minutes. In Kaunas it is not common to have face-to-face interviews; therefore a written questionnaire is sent by post to the selected people. The questionnaire was piloted by all partners, with specific attention for comprehensibility, clarity and duration and was adapted at some points based on outcomes of these pilots.
The final questionnaire was structured along four main clusters of questions: I. Green and Blue Spaces; II Residential situation: Dwelling & Neighbourhood; III Wellbeing and Health; IV Personal characteristics. For each mechanism are questions about availability, use, importance and satisfaction. In the sequencing of the questions we strove for a coherent set of questions per cluster moving from general to specific and from ‘’easy’’ to more intruding questions. Furthermore, most of the answer categories moved from neutral negative towards positive items. For all answers showcards were developed by RIVM, to make it easier for both interviewers and respondents, and to speed up the interview process. A separate instruction document was developed to train the interviewers. The questionnaire ended with an optional a pencil paper attention test (Color Trails Test (CTT-A)) (D’Elia et al).
Finally for the smartphone study at least 100 volunteers from each country were randomly selected from the participants of the questionnaire survey who indicated that they were willing to participate in the smartphone study. For these subjects, during seven subsequential days, the emotional state of the subject, the local environment (e.g. different quantities or qualities of natural space) and the social setting were assessed with the smartphone and the innovative Calfit technology. Besides objective geolocation and physical activity (see section Characterisation the natural environment), subjective data on stress reduction/restoration and social contacts were collected simultaneously. The latter data were collected through interactive diaries capable of eliciting ecological momentary assessment (EMA).
From the people who participated in both the questionnaire survey and the CALFIT study and who indicate they wanted to volunteer, 80 people (20 in each case city) were approached for semi structured interviews. These interviews were conducted to gain more detailed information on specific topics included in the questionnaire survey and CALFIT/EMA. Topics addressed included the motivation for travel routes, the associations of natural environment with mood, behaviour and well-being, the attitude towards and importance of (experiences with) natural environment, and reasons for using or not using the natural environment.
WP 2 Results
The research questions addressed were:
How can we explain the indications that close contact with nature brings benefits to human health and well-being?
1. What quantitative and qualitative characteristics of the natural environment are important?
2. How does the way people perceive the natural environment influence this association?
3. What is the effect of time spent in the natural environment?
4. Does it matter how important the natural environment is for people?
5. How do potential mechanisms interact?
6. Are there differences between subpopulations in these associations?
7. Does the context in which it takes place matter?
Main conclusions (methods)
There are several conclusions drawn on the used methodology:
• Combination of methods produced a rich set of data;
• Ambitious fieldwork;
• Innovative (e.g. smartphones);
Main conclusions (content)
• Having green and blue space in your surroundings is important for people;
• People spend most time in the natural environment nearby;
• More time spent in the natural environment is associated with higher mental health scores, higher frequency of social contacts and more physical exercise;
• The way people perceive the natural environment and the importance they attach to it for health-related activities (e.g. social activities, physical exercise) is stronger and more consistent associated than the quantitative characteristics of the natural environment;
• Perceived quality characteristics of natural environments (“variety in terms of plants and water”, “familiarity”, “colour” and “sound) seem to influence restoration of stress;
• If people visit a natural environment, then that is determined by a broad set of indicators, including their age, having young children, owning a dog, perceived quality and perceived quantity, a.o. things;
• For people with a low educational level, contact with nature may be more beneficial than for people with a higher educational level;
• There are clear differences between the four cities;
• In the densely populated city of Barcelona, there were some stronger effects than in the other greener cities;
• The mechanism is complex and should be considered in a wider (personal/physical/social/cultural & climate) context.
Take home messages
The conclusions have led to several general statements to be used by policy makers.
• Providing attractive and accessible natural environments nearby may improve health, in particular for specific groups such as the lower SES and in densely populated cities;
• Presence and size of the natural environment are not the only things that matter;
• Quality aspects are important as well;
• Taking into account the association between perception of the natural environment and health determinants, it is also important to know how people perceive the natural environment and why they use a natural environment or not from a health perspective; to create healthy designed natural environment, it is thus important to involve users of the natural environment.
• There are differences between cities, likely to be caused by local differences. Therefore creating healthy designed natural environment requires knowledge about the local context.
W3 Epidemiological studies to examine long term effects of the natural environment
WP3 methods
By using existing epidemiological studies and registries and linking these to the natural space indicators described earlier, the association between natural environment and a range of different long term health outcomes was examined in an efficient and cost effective manner. PHENOTYPE makes use of 16 existing cohorts and registries with good health outcome data in Spain, the Netherland, Lithuania, and United Kingdom, linking these to newly created natural environment indicators. Comparable estimates were produced for various regions in Europe for the associations with pregnancy outcomes, foetus development, children’s health and adult population morbidity and mortality.
Specifically focus was on:
▪ the natural outdoor environment and ethnicity, socio-economic status, women´s health and pregnancy outcomes;
▪ the natural outdoor environment and foetus development, birth weight, and gestational age;
▪ the natural outdoor environment and general development, neurodevelopment, cognitive function and respiratory health in children;
▪ the natural outdoor environment and respiratory health in children;
▪ the natural outdoor environment and obesity and sedentary behaviour in children
▪ the natural outdoor environment and general health, physical activity, specific morbidity and mortality.
The assessment of natural environment indicators was mainly based on satellite data and land use maps as CORINE and Urban atlas, and sometimes local data. This restricted to some extent the evaluation of the association with the natural environment, but this was the only realistic and achievable approach. All studies examined the role of socio-economic status, which was suggested as an effect modifier for the relationship between exposure to the natural environment and health benefits. Some cohorts such as the Born in Bradford study offered a unique opportunity to investigate the role of ethnicity in the relationship between exposure to the natural outdoor environment and health benefits, in Bradford study half of the participants are from Pakistani background, with information on both the mother and baby from pregnancy to early years in life.
Work package 3 studied birth outcomes related to access to natural spaces. Also children’s health effects were studied in relation to access by distance to green space. In adults, the effects on mental health were studied in relation to distance to parks or green spaces. Different mental health indicators were used in these studies like visit to specialists or the use of certain medication. In Lithuania more specifically the effects on cardiovascular health was studied in relation to access to green. Another specific study was the work on depressive symptoms in pregnant women in relation to distance to green.
Workpackage 3
Results and Conclusion
An increase in green space will lead to:
▪ Increases birth weight;
▪ Reduces mental health problems in adults/pregnant women;
▪ Improves cognitive function in children;
▪ Reduces behavioural problems in children;
▪ Reduces sedentary behaviour in children;
▪ Produces mix results for asthma in children;
▪ Reduces cardiovascular disease and mortality in adults;
▪ Reduces blood pressure in pregnant women.
In most of these studies people with low SES appear to benefit more. Furthermore, there is an indication that surrounding greenness is more beneficial than access.
An additional need for research has been discussed. The following needs were suggested:
▪ Longitudinal studies
▪ Intervention studies
▪ Contribution of various mechanisms
▪ More on where, when, how much, what type
▪ Quality assessments (e.g. audits)
WP 4 Methods Experiments to examine short term effects of the natural environment
To examine short term effects of the natural environment on health and well-being, one or more experimental studies were conducted in each country in which individuals were exposed to different types of natural and urban environments (i.e. environmental conditions). The majority of data collection was field-based to maximise the ecological (as well as internal) validity of any observed effects.
Using a range of psychological and physiological indicators relevant to the various possible mechanisms, and healthy and patient population groups (with mental and/or somatic morbidities) we collectively explored:
- Preventive and therapeutic effects of natural environments.
- Immediate and sustained changes in affective, cognitive and physiological responses indicative of well-being while engaged in a natural environment, and after leaving a natural environment
- Neurobiological responses to viewing natural or urban scenes before/after experiencing stress.
A randomised cross-over design, where possible, was used. Also a ccommon set of core indicators was applied. The protocol was standardized.Healthy unstressed adults, were to walk in non-stressful/pleasant urban areas vs. green vs. blue areas. The instorative effects were studied and that was done by single and repeated exposures.
Through variation in experimental design, each partner made a novel contribution(s) to areas as:
▪ UK: In healthy individuals, Study 1 compared immediate and post-exposure psycho-physiological effects of urban versus natural environments to explore whether any beneficial effects were sustained following single exposures; Study 2 used longer-term follow-up and repeated exposure to natural environments to explore whether any effects are accumulated, sustained or attenuated.
▪ Netherlands: an experimental functional Magnetic Resonance Imaging (fMRI) study was conducted in healthy individuals to investigate neurobiological responses to viewing natural or urban scenes before/after experiencing stress; i.e. whether viewing natural compared to urban scenery can prevent or buffer against stress responses, and how this was represented in brain activation patterns.
▪ Spain: in individuals with elevated stress levels, group-based exposure and Ecological Momentary Assessment (EMA, using CALFIT technology) were used to explore the role of social interaction and the nature of physical activity, in immediate and longer term responses. Ecological validity was enhanced through ‘free-living’ activities within environments, rather than controlling activities, again, using EMA, GPS and accelerometry to monitor the nature (and perceptions) of this activity.
▪ Lithuania: a clinical population with established coronary artery disease (CAD) was recruited to evaluate the therapeutic effect of the natural environment. The outcomes of this experiment had direct clinical applications for the use of urban and different types of natural environment in cardiac rehabilitation.
WP 4 Results
A higher perceived restoration in natural (blue and green) was found compared to urban environments at 30 minute follow-up (end of walk). There was no distinction between the walks with or without blue space included.
Improvements in cognitive functioning from baseline (lab) to 60 minute follow-up (lab) were seen in persons walking in natural environments (blue and green) compared to those walking in an urban environment. Their cognitive functioning returns to below baseline levels in the urban environment.
Main findings in the preventive studies:
In healthy, unstressed adults, light intensity walk in a natural environment confers greater benefit for perceived restoration and cognitive function; but pleasant urban and natural environment walks reduced stress and improved mood for all, over and above a healthy, unstressed baseline.
In healthy, unstressed adults, repeated light intensity walks in a natural environment conferred similar changes each day (not differentially attenuated or increased by environment).
Implications: Promote walking in nature during work day for sustained cognitive performance benefit. This is beneficial for employee behaviour and employer support. The general outcome is that a walk in any pleasant environment is able to reduce stress.
Main findings in the therapeutic studies (Spain):
In people with poor mental health, the exposure (three hours) to natural environment) improved their mood, and decreased stress levels and sympathetic nervous system functioning in comparison to exposure to urban environments.
The data also showed that restoration, physical activity, and air pollution are possible mediators.
Implications: Promote use of natural walks for those with mental health problems. Natural environments with blue space (water) can favourably affect the parasympathetic-sympathetic balance.
Main findings in the therapeutic studies (Lithuania):
The study was done with patients with a cardiovascular disease history of a heart attack. A park exposure vs. an urban environment benefits for additional benefits for blood pressure reduction, exercise capacity, heart rate recovery, mood (affect) and reductions in cortisol
Implications: To include natural environments in cardiac rehabilitation walking programmes for additional psychological and cardiovascular benefits.
Take home messages
The preventive studies lead to the following message:
‘If you take your lunch-time walk in non-stressful environment, you will have improved mood and reduced stress levels. But if you choose a natural environment, you should perform better at work after returning to your desk’
The therapeutic studies have the following messages:
‘Natural environments should be considered for inclusion in physical rehabilitation after CAD events, for additional benefits for blood pressure reduction, exercise capacity, heart rate recovery and stress levels’
‘Prolonged exposures in green and blue natural environments for people with poor mental health appear beneficial for mood, with beneficial stress reducing effects in green environments’.
WP 5 and 6 Methods and Results Implications, policy and guidelines and involvement of stakeholders
Guidelines
PHENOTYPE has provided recommendations for policymakers and guidelines for professional practitioners involved with spatial planning and health to create natural environments that promote health and well-being. For this, the project focused on a human ecological perspective which allows for a better integration of human health needs into land use planning and green space management in both rural and urban area. Legal standards that have been developed with economic, technological and political priorities in mind, are leading in urban design. Whereas the lifestyle, sense of community, identity, and health and well being of local populations have been largely undervalued. The guidelines reflected the importance to consider environmental, social, economic and other components of the natural and built environments in ways that also take into account and result from the point of view of citizens. PHENOTYPE complemented the common quantitative approach by valorising the social/human functions of these environments, especially their contribution to promoting health and quality of life.
The guidelines for professional practitioners involved with spatial planning and health considered three core topics in relation to each of the natural environment being considered:
1. Qualitative characteristics of natural environments; recommendations concerning surface area, vegetation, water sources, ambient noise levels, views and microclimate;
2. Facilities, Maintenance and Services; recommendations about the kinds of communal facilities and services provided in each type of natural environment, as well as suggested levels of maintenance;
3. Accessibility Guidelines to Natural Environments; including requirements about access to different types of natural environments such as allotments, neighbourhood parks, children's playgrounds and nature reserves.
The baseline for the work was firstly the compilation and analysis of currently available information from existing databases and literature, and later new data collected by the project as described above. This was complemented by the engagement with the appropriate stakeholders to assess scope for development. These insights were combined into a conceptual framework on the underlying mechanisms of the effects of the natural environment on health and well-being.
Stakeholders and dissemination
The participation provided a forum for project assurance and benefits for PHENOTYPE were summarised as follows:
▪ A more robust evidence base on links between exposure to natural outdoor environment and human health/well-being for various regions in Europe. Hereby we expect to develop a better understanding of the potential mechanisms.
▪ A better integration of human needs into land use planning and green space management in rural as well as urban areas. Furthermore, the application of these needs in practical guidelines.
Stakeholder involvement was critical for bringing outside (policy) ideas into the research planning, to increase the usefulness of the research, and to assure a better implementation of the results of the project.
From the start of PHENOTYPE actively sought to establish and maintain relations and dialogues with and between key stakeholders from local, regional and national health and environment authorities, institutions and the international research community. These included policy makers, architects, urban planners, natural space managers, health professionals, and the international research community. This group was highly diverse, as we were looking at a range of professions within the subject areas of environment and health, from volunteers to scientists, community workers and policy developers. PHENOTYPE has been successful in its engagement activities, providing continuous opportunities for information exchange and collaborations. These contributed to strengthening networking between researchers, policy-makers and stakeholders in order to facilitate the transfer of scientific knowledge to policy development, to exchange ideas about best practice and to help identify emerging issues on the natural outdoor environment and its mechanisms to improve health.
The PHENOTYPE website www.phenotype.eu provided and still provides an overview of the project, progress, actualities, surveys and publications. The site has a sign up form for newsletters and e-alerts through which all stakeholders are regularly informed. It guarantees continuous visibility, and provides a means for interested parties to respond to activities, or to contact us with invitations to attend workshops, etc. PHENOTYPE is also found on social media twitter @greenhealth4eu (300 followers), facebook (92 ‘likes’) and LinkedIn (60 members). The PHENOTYPE databases and overall results will be exploitable by reseachers and practioners at national and international level in areas including urban planning and health.
Method
Indicators, Guidelines and Recommendations
A number of core indicators were identified, both qualitative and quantitative, which may be helpful in a context of providing and monitoring of public green and blue natural spaces. Thirty-eight indicators related to nine categories of variable (described in detail in WP5 reports) play a role in the relations between public green and blue spaces and positive human health and well-being including:
• Indicators to assess the attractiveness of public green space to promote health promotion
• Multiscale analysis (street, neighbourhood, city, region).
The nine Categories of Key Variables are:
• Ownership
• Size/Shape
• Biological characteristics
• Functional uses
• Localisation
• Management
• Community and group identity
• Climate/Weather
• Nuisances
It was also found that:
A. Research confirms that the specific characteristics of public green spaces influence their attractiveness for individuals and population groups, but these characteristics are still not well understood. The definition of attractiveness is dependent on multiple factors including the specific culture of users as well as the bio-physical and geographical characteristics of public green spaces, and their intended use by individuals and groups.
Policy makers and professional practitioners should broaden their approach about the recommended size of public green space. There is no validated norm or standard for the size of public green space! Instead, PHENOTYPE has formulated nine key variables of the characteristics of public green spaces that define their attractiveness. These key variables are 1.) Ownership 2.) Size and shape 3.) Biological characteristics 4.) Functional uses 5.) Localisation 6.) Management 7.) Community identity 8.) Climate/weather 9.) Nuisances. These variables have been validated by stakeholders in both the public and private sectors in 4 European countries.
B. The PHENOTYPE study and other research show that the health benefits of access to green spaces varies between different population groups. For example, the health of women (pregnant or not), foetus, children, cardiac-patients and especially populations with relatively low socio-economic status, benefits more than other groups from access to public green spaces, residential proximity and uses of public green and blue spaces when these are localities for health promoting behaviours.
• Consequently, policy makers cannot avoid dealing with rights of access to and multiple uses of public green spaces for specific user groups, especially those with relatively low socio-economic status.
• The provision and maintenance of public green spaces involves political choices that have consequences for the promotion of public health. Beyond a common concern about the quantity of public green spaces in large urban areas, it is important to address social justice, such as issues of equity and fairness, especially those populations in residential neighbourhoods that do not live nearby these kinds of public spaces
C. The PHENOTYPE study and other research confirm that investments in the provision and the maintenance of public green spaces are also investments in public health. Public green spaces serve multiple functions, having co-benefits such as providing a cooling effect during periods of extreme heat; the absorption of storm water in case of prolonged rainfall or flash flooding; a retreat from relatively high ambient noise levels; and attractive localities for different kinds of health promoting behaviours (e.g. physical activity, children’s play, social interaction).
• Consequently, valuations of public green spaces should be requested by policy makers before they decide about the provision and maintenance of these spaces. The intrinsic value of these spaces, and especially those having high biodiversity, should not be equated with exchange values of land markets.
D. Research shows that the multiple uses of public green spaces highlight conflicts of interest between local residents, visitors, elected officials and civil servants especially concerning their rights and responsibilities. Public green spaces can be localities for small group or larger community meetings, recreational activities of members of local associations, or informal interaction between individuals. These spaces can also be sites for incivilities, drug trafficking or muggings.
• Therefore, appropriate landscape designs, management strategies and regular surveillance are necessary to prevent public green spaces becoming unattractive for health promoting behaviours.
• Alternative maintenance projects and management regimes founded on common property rights can enable local communities to maintain and manage these spaces.
E. Research shows that a lack of information and coordination between departments in local and national authorities concerned about land-use planning, green space management, transport and road infrastructure, social care and public health is not only common but also problematic and should be addressed.
• Consequently, intersectoral initiatives developed from a strategic and holistic vision, can provide a shared framework for the provision and maintenance of public green spaces that are attractive localities for healthy behaviours. This kind of initiative could begin with pilot projects in order to show the added value of intersectoral collaboration. Outcomes can only be effective if there is strong political commitment and sufficient resources.
• General practitioners should be interested in health promotion and prevention by diverse uses of public green and blue spaces. Doctors could attend public meetings about land use planning projects by local authorities in order to integrate health promotion into decision making processes. Public authorities should inform citizens about the health benefits of contact with public green and blue spaces.
F. Research shows that there is a lack of data and information about the characteristics of public green spaces in several European countries. Proxy measures are frequently used rather than measured variables in specific localities. This “missing information syndrome” is even greater with respect to the diversity of users, the multiple and diverse functions of public green and blue spaces, and the behaviour of residents and visitors in public green spaces.
• Consequently, there is an urgent need for policy makers and professionals to have access to reliable data and different kinds of information about the inherent characteristics and the multiple functions and uses of public green spaces. Systematic monitoring of these spaces is necessary.
• In addition to allocating public funds to fill this gap, citizen science could contribute to the collection and dissemination of data and information if local authorities and institutes of higher education and NGOs develop partnerships for their mutual benefits.
Overall conclusion
PHENOTYPE has addressed many of the shortcomings of the previous studies and has:
▪ Produced a more robust and comparable evidence base on links between exposure to natural outdoor environment and human health and well-being;
▪ Extended the evidence base to new outcomes and vulnerable populations e.g. pregnant women and their foetus, children, chronic respiratory and cardiovascular patients, ethnic minorities and low social economic class;
▪ Examined the proposed mechanisms (physical activity, stress, social contacts, and environmental risk factors) simultaneously in a large sample in various countries. This enabled us to study specific factors while adjusting for others, and thereby strengthening the interpretation of the results;
▪ Conducted comparable studies across Europe and produced evidence for North Western, Eastern and Southern Europe. This provided insights into regional, social and/or cultural differences in relation to natural space;
▪ Examined the effects of green space and also of blue space;
▪ Minimized the potential differences due to classification of natural space, by combining the use of conventional maps and data sources with remote sensing data and aerial photography and audit data, gather individual-level detailed data through of subjects living in the areas through questionnaire surveus, smartphones, and in-depth interviews and engaged stakeholders for further interpretation of data and discuss the implications of the research outcomes for planning and policy;
▪ Made classifications for the type and level of the indicators, which is important for policy makers;
▪ Examined the importance of both quantitative (amount, type, access, use) and qualitative characteristics (acoustic quality, identity, variety, safety) of the natural environment;
▪ Considered actual use of the natural environment, an often neglected but fundamental indicator in relation to exposure to natural environments.
▪ Considered the perception of the natural environment, also often neglected, but important to gain insight into what is important to people, and in how and why people use (or do not use) the natural environment.
▪ Robust field experiments have indicated that exposure to natural environments can provide acute therapeutic benefits for cardiac patients and those with poor mental health, and confers preventive cognitive benefits to healthy people which are not reduced on repeated visits.
The project has found that in general long term exposure to green space has a range of beneficial health effects including e.g. a reduction in cardiovascular disease, mental health problems, obesity and sedentary behaviour, blood pressure, an increase in birth weight, an improvement in cognitive function and behaviour in children and mixed results for asthma, which depended on the type of green space. Also short term exposure to green space has beneficial effects including for example an improvement of mood. In general, the exact amount and type of green space needed is still not fully clarified, but both access to green space and surrounding greenness may have beneficial effects depending on the underlying mechanisms. We found also that perception and use of green spaces are important in the observed effects. Exposure to green space is related to physical activity, social contacts and mental health, but the extent varies by country. The benefits of blue space on health were less clear. Policy makers and professional practitioners should encourage the presence of green space but broaden their approach about the recommended size of public green space. There is no validated norm or standard for the size of public green space. Instead, PHENOTYPE has formulated 9 key variables of the characteristics of public green spaces that define their attractiveness. These key variables are 1.) Ownership 2.) Size and shape 3.) Biological characteristics 4.) Functional uses 5.) Localisation 6.) Management 7.) Community identity 8.) Climate/weather 9.) Nuisances. These variables were validated by stakeholders in both the public and private sectors in 4 European countries.
Potential Impact:
PHENOTYPE set out produce more robust evidence base on links between exposure to natural outdoor environment and human health and well-being, and a better integration of human health needs into land use planning and green space management in rural as well as urban areas.
The project has delivered a wide range of results. These are produced in different formats: scientific reports; scientific articles; guidelines and recommendations for stakeholders or professional practitioners; stakeholder analysis and engagement plan.
Each of these formats have their own value in dissemination of the results of the project.
The results in PHENOTYPE have been produced in four work packages (WP). Each WP has produced its own reports with results, as well as articles in peer reviewed journals. There are different categories of stakeholder groups that are addressed in PHENOTYPE.
- General public: NGOs, Community Associations at different levels: national and local;
- Practitioners: urban and land-use planners; health promotion professionals; managers and designers of public green spaces.
These stakeholder groups have been identified within the consortium by the partners, in collaboration with stakeholders attending the different meetings within PHENOTYPE.
- Scientific reports: Results based on reports of the different WPs aim at scientists and policymakers. These reports have been or will be distributed by the work packages and disseminated via the PHENOTYPE website. Other stakeholders can also access these reports.
- Scientific articles: The scientific articles have been produced by the members in the PHENOTYPE consortium. Most articles have been published in peer reviewed journals. Some have been submitted. The abstracts of these articles are provided in Annex 1.
- Guidelines based on conceptual framework: WP5 has produced a report on guidelines for policymakers. These guidelines are linked to the results of this report. Professionals and practitioners, as mentioned above, might find these guidelines also very useful.
- General public: The general public has not been a prominent stakeholder so far for the consortium to disseminate the results, however, the partners have presented the project at public events throughout the project.
Throughout the project, partners have contributed to a significant number of (newspaper) interviews and video reports in the popular media. The general dissemination about the concept of the PHENOTYPE project to the general public has taken place in different countries. In addition, video messages were produced and disseminated via the project website (www.phenotype.eu).
Stakeholder interaction: The interaction with stakeholders outside the consortium has been analysed in PHENOTYPE Dissemination Strategy. Furthermore, the most favorable engagement with stakeholders has been described.
The results of the research of PHENOTYPE are important for different stakeholders. Results of research projects do have more value if they are translated into practical and understandable recommendations. This process is not always easy. Results from research always raise more questions. However, each result will point in a certain direction. If some health benefit can be added to a result out of the PHENOTYPE research it should be mentioned.
The presented results of the different studies within PHENOTYPE all have some value for implementation. Science produces a lot of results which can lead to more scientific questions. But there are always results that can be used to improve our world. Sometimes these results are still very indicative. Sometimes results are not causal to explain mechanisms. But always there are possible conclusions that cause no harm to take action upon.
A result can be descriptive and confirm common knowledge. There are some items that have been studied that are a proxy for a range of factors that cannot be described. For example, exposure to green in a park can stand for visual exposure, or exposure to odours, noise or temperature. If there is some positive health effect associated with exposure to green quite often we cannot determine any causal factor. Some exposure or characteristic factors (of natural space) provide an association with factors of effect without any causal relationship. There can be outcomes of interest (social or health effects) that may be influenced by factors related to natural space, but then there are also other factors related to the same outcomes. Another issue is the uncertainty about the representativeness of the exposed group. The results in some studies are not always making distinction between different subgroups such as socioeconomic, vulnerable or ethnic groups.
So, each result has to be merited for its own context of the study.
The results of the research of PHENOTYPE are important for different stakeholders. Results of research projects do have more value if they are translated into practical and understandable recommendations. This process is not always easy. Results from research always raise more questions. However, each result will point in a certain direction. If some health benefit can be added to a result out of the PHENOTYPE research it should be mentioned.
To enhance the potential impact of the project and improve dissemination at all levels, PHENOTYPE has released a clear set of recommendations. These are formulated based on the scientific field work and on literature analysis.
Field work
- The interconnections between exposure to natural outdoor environments, in both rural and urban settings
- Pregnant women have lower exposure to air pollution if they spend more time in greener surroundings. The location of residence and its exposure remains the same if this is not within 100 m of greenness. The effect might than be less. Greenness in residential areas seems to benefit pregnant women.
- Women that visit green areas, more specifically parks, show a beneficial effect on foetal growth. This effect is mostly seen in areas with low surrounding greenness. The implementation of more greenness or use of greenness in lower SES women seems to be beneficial on some fetal growth measures.
- When persons are near greenness general and mental health are better self-perceived and this is more consistent for surrounding greenness than for access to green spaces. This is also stronger for women and residents of non-densely populated areas.
- The association between the use of the park and residential proximity to the park revealed that women living more than 300 meters from a green space and who used the space more than 4 hours per week showed more depressive symptoms and poor and very poor perceived general health as compared to those who used the park less than 4 hours per week and residential proximity was more than 300 meters. This prevalence of depressive symptoms and poor and or very poor perceived general health was higher in women than in men.
- Less cardiovascular problems could be obtained by higher use of park and living nearer to green space. Public health policies aimed at promoting healthy lifestyles in urban settings could produce cardiovascular benefits.
- In women the probability of blood pressure increased by 9%, and that of high-normal blood pressure-by 14% for every 300 meters increase in the distance to green spaces. A beneficial impact of nearby city parks was seen on blood pressure amongst 20- to 45-year-old women.
- In line with these cardiac results it is seen that walking in a park had a greater positive effect on patients’ cardiac function than walking in an urban environment, suggesting that rehabilitation through walking in green environments after coronary events should be encouraged.
- Some inconclusive results show that more residential greenness was associated with worse mental health (more conditional problems and less prosocial behavior) in children whose mothers had a higher education level.
Underlying mechanisms
- The exposure related results do not provide any information on the underlying mechanisms.
- Residential surrounding greenness and subjective residential proximity to green spaces were associated with better self-perceived general health.
- Indications were found for mediation of these associations by reduced psychological distress and improved self-perceived social support and to less extend by enhanced physical activity. These mediators altogether could explain about half of the surrounding greenness association and one-third of the association for subjective proximity to green spaces. We observed suggestions that psychological distress and self-perceived social support might be more relevant for men and those younger than 65 years.
- The study on the association between visits to green space and mental health provides support for the hypothesized physical activity and social contacts mechanisms explaining the mental health benefits of visiting green space.
Effects for different population groups
- Positive results on the pre-born or born child is seen if their mothers make use of natural spaces during their pregnancy. This effect can differ in distance form residence to natural space or between with more or less greenness. There also seem to be differences between ethnic and socioeconomic groups in the city on better foetal growth. More beneficial effect in lowest socioeconomic group.
- The implementation of more greenness or use of greenness in lower SES women seems to be beneficial on some fetal growth measures.
- Children are another important group within the population. Findings support beneficial impacts of contact with green and blue spaces on behavioral development in schoolchildren. This supports the use of for more green/blue space play of schoolchildren.
- Greenness is good for reducing obesity and excessive screen time, be it residential surrounding greenness, forest or park. However, living near parks gives higher relative prevalence of current asthma.
- The study on determinants of visits to natural environments in the neighbourhood indicates which personal and environmental characteristics predict whether or not people visit neighbourhood nature. The identification of personal determinants reveals which people visit neighbourhood nature frequently and thereby which target groups need to be stimulated into visiting these environments more often. Equivalently, the identification of environmental determinants suggests which features of nature are worth investing in order to promote visits.
Effects of different characteristics of the natural outdoor environment
Quality characteristics of natural environments seem to influence restoration, therefore it is recommended to consider these characteristics when opting to design or improve natural environments which allow for restoration.
Preventive and therapeutic effects
- Several of the results mentioned above relate to preventive effects. For example those of the unborn child or perinatal effects. Also there seems to be an effect by living near greenness on reduction of number of children with obesity.
- Providing easy access to green spaces to enable people to visit green spaces, may be a promising potential public health strategy to protect and improve mental health, especially for people with a low level of education.
Implications for land-use planning and green space management
There are no clear specifically n land-use planning or green space management other than linking the results of the described sections above to those stakeholders related to land-use planning and green space management. The interest of insurance companies to link green space management to prevention of health effects is promising. The dissemination of the guidelines to stakeholders in the domains of land-use planning, green space management and additionally health insurance companies is recommended.
Guidelines
Work has been carried out to strengthen the conceptual framework of the health benefits of public natural space, which leads to guidelines. The implications of all of these findings for land-use planning and green space management are synthesized and transformed into guidelines. These guidelines consider three core topics in relation to each of natural environment being considered:
1. Qualitative characteristics of natural environments
(recommendations concerning surface area, vegetation, water sources, ambient noise
levels, views and microclimate);
2. Facilities, Maintenance and Services
(recommendations about the kinds of communal facilities and services provided in each
type of natural environment, as well as suggested levels of maintenance);
3. Accessibility Guidelines to Natural Environments
(including requirements about access to different types of natural environments such as
allotments, neighbourhood parks, children's playgrounds and nature reserves).
Where feasible the results of this work are incorporated in the implementation activities at each of the participating cities.
In so far results on these topics have been produced these will be used in the recommendations towards the implementation by the different stakeholders. This has been done in the workshops and final meeting with stakeholders. Furthermore, the consortium partners will use the compact format of the guidelines to further dissemination at a national level.
The results of the scientific filed work have been extracted from the different deliverables and the summary abstracts of the scientific papers. Most of these papers have been published.
The results have been discussed by the partners in the consortium and where possible with local or regional stakeholders in the participating countries.
The dissemination of scientific project results should have a prominent place in a large project. However, the larger the project, the more results are there to analyse, it is seen that it takes more time produce information to disseminate. Furthermore, results of scientific projects preferably are used for communication with different stakeholders.
The identification of sensitive persons (to new information on health and natural spaces) in different organisations was considered to be an important aspect of dissemination approach. Specifically for the topic of PHENOTYPE it is considered important to bring public health and urban planning together.
The recommendations of PHENOTYPE should be brought down to a more local level to become more practical. Moreover, a great opportunity is seen in bringing science, policy and practice together based on the PHENOTYPE results. To make the indicators valid for different cities one has to sit down with local authorities. There should be a link to monitoring these indicators. Architects have been mentioned as a missing link if evaluation of plans are considered.
These aspects of the work of PHENOTYPE are useful for exploitation in different cities. The outcome of the fieldwork is already been used in follow-up studies in other places or countries. For example, in the Netherlands the developed indicators will be used in a planned field study in three cities to compare different SES neighbourhoods on the impact of green on health. The socioeconomic health differences between neighbourhoods have to be reduced after this project. The results on social aspects of the PHENOTYPE project will be used in the implementation of the strategy to communicate with representatives of the different neighbourhoods.
Continuous work
Following the presentation of the PHENOTYPE results during the Final Stakeholder meeting in Brussels (December 2015), these have been taken into account for discussion during a workshop of the Institute European Environmental Policy (IEEP), addressing health and social benefits of nature to forge biodiversity protection. Our intention is to raise further awareness to the subject and contribute to further policy discussions, at regional, national and international level.
For example, in the Netherlands the results of PHENOTYPE have been discussed at a meeting of professionals of all the National Public Health Services, including a presentation. The outcome was to have factsheets on the policy implications of the conclusions on the results of PHENOTYPE. The results of PHENOTYPE are considered in a new tool being developed by the Province of Gelderland, the Netherlands, to support local communities in a quick scan on environmental issues in relation to spatial planning. The indicators developed by PHENOTYPE are considered for the green and health part of this tool.
In Stoke-on-Trent, one of the full-time PHENOTYPE researchers has go on to work within the City Council planning department with a remit to incorporate health into planning processes; e.g. ensuring Health Impact Assessments are completed and done so with sufficient rigor and regard for health-promoting aspects of neighborhood environments, such as natural environments. Some of the PHENTPYE data sources will also be linked with other health and local authority environment data to develop Health Urban Planning indices to aid planners and developers in maximizing health potential of future developments. This includes a new collaboration between the Staffordshire University team and the local hospital trust to explore environmental correlates of CVD risk factors using data from their Clinical Pathology lab. Finally, the University has established a new Centre for Health and Development (CHAD, www.chadresearch.co.uk); a collaboration between the Staffordshire University and local authorities. One of CHAD’s key thematic research area around Healthy and Sustainable Places and Communities, in which natural environments will be an important part.
The consortium partners are going to continue to produce more scientific articles based on the project results. Some of these articles have already submitted for peer review to scientific journals or will be submitted during 2016.
Contacts with other projects on green space and health offer further opportunities to disseminate PHENOTYPE results at meetings or conferences. Project partners intend to present at the International Society for Environmental Epidemiology (ISEE) 2016 in Rome, European Innovations Ecosystems Conference in Brussels, EU Green Week, INCHES (global network of people and organizations interested in promoting the protection of children from environmental and safety hazards) in Barcelona (September 2016) and at One Health / EcoHealth Brussels Workshop 2016. Conferences have also been attended during the official lifespan of the project to disseminate information and ongoings of the project as wide as possible (such as the annual ISEE conference), in particular to network with stakeholders and reach those with and interest and professional activity in policy steering environments.
The distribution of three PHENOTYPE documents could have a positive effect on putting green, natural spaces and health on the agenda of cities, or even countries. These documents would be in the format of a brochure:
- Guidelines
- Indicators (with addition of practical suggestions)
- Public health Implications
This is currently under development and will be disseminated starting in 2016, while final scientific papers are published.
Those publications which could not be entered in the NEF, but have been published, or are close to being published, are:
WP2:
1. Berg M van den, Poppel M van, Kamp I van, Ruijsbroek A, Triguero-Mas M, Gidlow C, Nieuwenhuijsen MJ, Gražulevičiene R, Mechelen W van, Kruize H, Maas J. Physical activity and loneliness mediate the association between time spent visiting green spaces and mental health: a multiple mediation analysis. (Under review, Journal of Public Health)
2. Ruijsbroek A, Droomers M, Kruize H, Gidlow C, Grazuleviciene R, Andrusaityte S, Maas J, Nieuwenhuijsen M, Triguero-Mas M, Masterson D, Ellis N, Hardyns W, Stronks K, Groenewegen P. Neighbourhood green space, social environment and mental health: an examination in four European cities. (Under review, European Journal of Public Health)
3. Ruijsbroek A, Droomers M, Kruize H, Gidlow C, Masterson D, Hurst G, Andrusaityte S, Nieuwenhuijsen MJ, Maas J, Hardyns W, Stronks K, Groenewegen PP. “Does the health impact of exposure to neighbourhood green space differ between population groups? A study in four European cities" has been successfully submitted online and is presently being given full consideration for publication in Journal of Epidemiology & Community Health.
4. Magdalena van den Berg. Physical activity and loneliness mediate the association between visits to green space and mental health: a multiple mediation analysis. (Under review, Public Health)
5. Magdalena van den Berg. Visiting green spaces mediate the associations between quantity of green spaces in the living environment and mental health. (In preparation)
WP3:
1. Magdalena van den Berg. Health benefits of green space in the living environment: a systematic review of observational studies. Urban Forestry & Urban Greening 14, 806–816. doi.org/10.1016/j.ufug.2015.07.008
2. Triguero-Mas M, Dadvand P, Cirach M, Martínez D, Medina A, Mompart A, Basagañ X, Gražulevičienė R, Nieuwenhuijsen MJ. Natural outdoor environments and mental and physical health: Relationships and mechanisms. Environment International. Volume 77, April 2015, Pages 35–41.
3. Gascon M, Triguero-Mas M, Martínez D, Dadvand P, Rojas-Rueda D, Plasència A, Nieuwenhuijsen M. Residential green spaces and mortality: A systematic review. Environ Int. 2015 Nov 2;86:60-67. doi: 10.1016/j.envint.2015.10.
4. Andrusaityte S, Grazuleviciene R, Kudzyte J, Bernotiene A, Dedele A, Nieuwenhuijsen MJ. Associations between Neighbourhood Greenness and Asthma in Preschool Children: a Case-control Kaunas Study. BMJ Open (Accepted for publication)
5. Balseviciene B, Sinkariova L, Grazuleviciene R, Andrusaityte S, Uzdanaviciute I, Dedele A, Nieuwenhuijsen MJ. Surrounding greenness, distance to city parks, park use and children mental health. Urban Forestry and Urban Greening. (Under review)
6. Gidlow CJ, Smith G, Wilson R, Trinder P, Martinez D, Grazuleviciene R, Nieuwenhuijsen MJ. Natural environments and cardiovascular prescribing in England. Landscape and Urban Planning. (Under review )
7. Stewart T. The natural outdoor environment and BMI in pregnant women in different regions in Europe. (Under review).
WP4:
1. Grazuleviciene et al. Effectiveness of a physical activity in urban natural environments on stress and cardiac function in coronary artery disease patients: a randomized trial. (Under review, BMC Cardiovascular Disorders).
2. Triguero Mas et al. The Effect of Different Types of Natural Outdoor Environments on People with Poor Mental Health in Catalonia. (Under review, PLOS ONE)
3. Jones et al. Psycho-physiological responses of repeated exposure to natural and urban environments. (In preparation, target journal - International Journal of Psychophysiology)
4. Hurst et al. A preliminary investigation into the mechanisms underlying the environment-health relationship: an image study. (In preparation, target journal – Journal of Environmental Psychology)
Dissemination materials will be also sent to the Network of the National Contact Points (NCPs) in Member States and Associated States. A news item regarding the PHENOTYPE recommendations will be submitted to the CORDIS database, and a press release will be prepared at CREAL and published coinciding with the publication of one of the main papers originating from WP2. This will also announce the completion of the project, and will be used to transmit a similar languages by the other Beneficiaries.
Meanwhile, the website www.phenotype.eu and the PHENOTYPE social media twitter (@greenhealth4eu), Facebook and LinkedIn, will continue to be active and function as reference sources and as tools for viral messaging.
Data originating from the PHENOTYPE project will be made available to Europe-based investigators at request, for which procedures are currently under development. In the long-run, exploitation of the PHENOTYPE results and the knowledge acquired during the PHENOTYPE project will be achieved via involvement of partners in other international projects, including those funded by the EU. Furthermore, the involvement of partners in policy networks at the national and international level, including different Directorates of the EU, Member States’ health ministries and their commissions, and regional health authorities, will facilitate the awareness of PHENOTYPE results and their possible use for the development and implementation of policies related to public health and environment.
List of Websites:
www.phenotype.eu
Diana van Gent
Project Manager
Centre de Recerca en Epidemiologia Ambiental
Parc Recerca Biomèdica de Barcelona
Doctor Aiguader, 88
08003 Barcelona, Spain
Email: dvangent@creal.cat
Tel: +34 932 14 7355
Fax: +34 932 14 7301
The PHENOTYPE project objectives were to:
• Investigate the interconnections between exposure to natural outdoor environments, in both rural and urban settings, and better human health and well-being and particularly;
• Identify the underlying mechanisms at work;
• Examine the effects for different population groups;
• Examine the effects of different characteristics of the natural outdoor environment;
• Cover both preventive as well as therapeutic effects of contact with the natural environment;
• Address the implications for land-use planning and green space management, specifically focusing on the integration of human health needs, and translating the research outcomes into recommendations for policy makers and guidelines for professional practitioners.
PHENOTYPE found that in general long term exposure to green space has a range of beneficial health effects including e.g. a reduction in premature mortality, cardiovascular disease and mental health problems in adults; a reduction in blood pressure in adults and pregnant women; a reduction in obesity and sedentary behaviour, an increase in birth weight, and improvement of cognitive function in children. Furthermore, we found mixed results for asthma in children, depending on the type of green space. There are indications that the lower socio-economic groups seem to benefit more, and that surrounding greenness is more beneficial than access to green spaces further away.
Also short term exposure to green space has beneficial effects including for example an improvement of mood and reduction of stress levels. Furthermore, it helps for physical rehabilitation after cardiovascular disease events.
Spending more time in the natural environment is associated with higher mental health scores, higher frequency of social contacts and more physical exercise, but the extent of this association varies by country. The perception of the natural environment is also important in the observed effects, and perceived quality characteristics of natural environments seem to influence restoration of stress. The benefits of blue space on health were less clear. In general, the exact role of amount and type of green space needed is still not fully clarified - there is an association with health outcomes and access and amount of green space, but not so much with the health determinants (physical activity, social contacts etc.). However, the health determinants do show an association with use and perception of the natural environment. Based on these results, we recommend that policy makers and professional practitioners should encourage the presence of green space but broaden their approach about the recommended size of public green space. There is no validated norm or standard for the size of public green space. Instead, PHENOTYPE has formulated nine key variables of the characteristics of public green spaces that define their attractiveness.
These key variables are: 1) Ownership; 2) Size and shape; 3) Biological characteristics; 4) Functional uses; 5) Localisation; 6) Management; 7) Community identity; 8) Climate/weather; 9) Nuisances.
These variables were validated by stakeholders in both the public and private sectors in four European countries.
Project Context and Objectives:
Background
At the start of the PHENOTYPE project in 2012, indications existed that close contact with nature brings benefits to human health and well-being, however, the mechanisms were not well understood. Also, most of the research had been conducted in the North West of Europe and USA. A more robust evidence base on links between exposure to natural outdoor environment and human health and well-being across Europe was needed, including a better understanding of the potential mechanisms. Inconsistency and variation in indicators for green or natural space had often made it difficult to compare results from different studies. Furthermore, there was a need for better integration of human health needs into land use planning and green space management in rural as well as urban areas.
Aims and objectives
The PHENOTYPE project objectives were to:
▪ Investigate the interconnections between exposure to natural outdoor environments, in both rural and urban settings, and better human health and well-being and particularly
▪ Identify the underlying mechanisms at work
▪ Examine the effects for different population groups
▪ Examine the effects of different characteristics of the natural outdoor environment
▪ Cover both preventive as well as therapeutic effects of contact with the natural environment
▪ Address the implications for land-use planning and green space management, specifically focusing on the integration of human health needs, and translating the research outcomes into recommendations for policy makers and guidelines for professional practitioners
The project used a multidisciplinary and integrated approach using the best and most efficient methods to understand the relation between exposure to the natural environment and health. It specifically addressed in-depth the potential mechanisms associated, and translate these findings into potential policies and management practices, taking into account potential regional, social and/or cultural differences. Stakeholders played an active role throughout the work.
The natural outdoor environment ranges from rural to urban settings, and the proposed work included and has evaluated:
- Green spaces (e.g. roof gardens, city parks, court yards) and “greenery” (forests, nature reserves/parks, mountains, farmland, trees, landscaping etc.)
- Blue spaces (water such as canals, ponds, creeks, rivers, beaches etc)
We examined the importance of both quantitative (e.g. amount, type, access, use) and qualitative characteristics (e.g. acoustic quality, identity, variety, safety) of the natural environment by collecting detailed data on these characteristics using a combination of methods of techniques. We focused on natural environments at different scales and distances of the home (city/town, neighbourhood, street level) and where possible also at other places where people stay (work, school, on their way to home/school, recreational). In addition, we considered actual use of the natural environment.
We explored underlying mechanisms related to:
▪ stress reduction/restorative function
▪ physical activity
▪ social interaction/social cohesion
▪ exposure to environmental hazards (noise/acoustic quality, air pollution)
Both preventative and therapeutic effects (in patients) have been considered. Outcomes of interest that were evaluated, were:
▪ general health and well-being (including medically unexplained symptoms
(MUPS))
▪ mental health/cognitive development
▪ stress/mood
▪ all cause, cardiovascular, cancer and respiratory mortality and morbidity
▪ birth outcomes
▪ obesity
▪ asthma
The project examined the effects for different population groups, including more vulnerable populations:
▪ pregnant women and/or foetus
▪ age groups (children)
▪ (lower) socio-economic status population groups
▪ ethnic minorities
▪ patients/people with specific health complaints
Comparative studies were conducted in different regions of Europe to examine any underlying regional, social and/or cultural differences related to the meanings, uses, mechanisms and health effects of the natural environment and we included the:
▪ North west (Netherlands, England)
▪ South (Spain)
▪ East (Lithuania)
Specific attention was paid to the application of knowledge to practice in close cooperation with relevant stakeholders. The implications for land-use planning and green space management have been addressed, specifically focusing on the integration of human health needs, and include an overall health impact assessment, including a conceptual framework.
Methods
Figure 1 (Annex I) summarizes the different parts of the study and the interdependencies between the different parts, namely the characterisation of the natural environment and the way it is used, examination of the underlying mechanisms in daily life settings, short and long term effects of the natural environment, and the implications for management and policy of the natural environment. In this section we will elaborate on each of these parts.
PHENOTYPE has addressed many of the shortcomings of the previous studies and has further:
▪ Produced a more robust and comparable evidence base on links between exposure to natural outdoor environment and human health and well-being;
▪ Extended the evidence base to new outcomes and vulnerable populations e.g. pregnant women and their foetus, children, chronic respiratory and cardiovascular patients, ethnic minorities and low social economic class;
▪ Examined the proposed mechanisms (physical activity, stress, social contacts, and to a lesser extent environmental risk factors) simultaneously in a large sample in various countries. This enabled us to study specific factors while adjusting for others, and thereby strengthening the interpretation of the results;
▪ Conducted comparable studies across Europe and produced evidence for North Western, Eastern and Southern Europe. This provided insights into regional, social and/or cultural differences in relation to natural space;
▪ Examined the effects of green space and also of blue space;
▪ Minimized the potential differences due to classification of natural space, by combining the use of conventional maps and data sources with remote sensing data and aerial photography and audit data, gather individual-level detailed data through of subjects living in the areas through questionnaire surveys, smartphones, and in-depth interviews and engaged stakeholders for further interpretation of data and discuss the implications of the research outcomes for planning and policy;
▪ Made classifications for the type and level of the indicators, which is important for policy makers;
▪ Examined the importance of both quantitative (amount, type, access, use) and qualitative characteristics (acoustic quality, identity, variety, safety) of the natural environment;
▪ Considered actual use of the natural environment, an often neglected but fundamental indicator in relation to exposure to natural environments.
▪ Considered the perception of the natural environment, also often neglected, but important to gain insight into what is important to people, and in how and why people use (or do not use) the natural environment.
PHENOTYPE found that in general long term exposure to green space has a range of beneficial health effects including e.g. a reduction in premature mortality, cardiovascular disease and mental health problems in adults; a reduction in blood pressure in adults and pregnant women; a reduction in obesity and sedentary behaviour, an increase in birth weight, and improvement of cognitive function in children. Furthermore, we found mixed results for asthma in children, depending on the type of green space. There are indications that the lower socio-economic groups seem to benefit more, and that surrounding greenness is more beneficial than access to green spaces further away.
Also short term exposure to green space has beneficial effects including for example an improvement of mood and reduction of stress levels. Furthermore, it helps for physical rehabilitation after cardiovascular disease events.
Spending more time in the natural environment is associated with higher mental health scores, higher frequency of social contacts and more physical exercise, but the extent of this association varies by country. The perception of the natural environment is also important in the observed effects, and perceived quality characteristics of natural environments seem to influence restoration of stress. The benefits of blue space on health were less clear. In general, the exact role of amount and type of green space needed is still not fully clarified - there is an association with health outcomes and access and amount of green space, but not so much with the health determinants (physical activity, social contacts etc.). However, the health determinants do show an association with use and perception of the natural environment.
Policy makers and professional practitioners should encourage the presence of green space but broaden their approach about the recommended size of public green space. There is no validated norm or standard for the size of public green space. Instead, PHENOTYPE has formulated nine key variables of the characteristics of public green spaces that define their attractiveness.
These key variables are:
1.) Ownership 2.) Size and shape 3.) Biological characteristics
4.) Functional uses 5.) Localisation 6.) Management
7.) Community identity 8.) Climate/weather 9.) Nuisances.
These variables were validated by stakeholders in both the public and private sectors in four European countries.
Project Results:
The PHENOTYPE project objectives were to:
▪ Investigate the interconnections between exposure to natural outdoor environments, in both rural and urban settings, and better human health and well-being and particularly;
▪ Identify the underlying mechanisms at work;
▪ Examine the effects for different population groups;
▪ Examine the effects of different characteristics of the natural outdoor environment;
▪ Cover both preventive as well as therapeutic effects of contact with the natural environment;
▪ Address the implications for land-use planning and green space management, specifically focusing on the integration of human health needs, and translating the research outcomes into recommendations for policy makers and guidelines for professional practitioners.
Methods
Figure 1 (Annex I) summarizes the different parts of the study and the interdependencies between the different parts, namely the characterisation of the natural environment and the way it is used, examination of the underlying mechanisms in daily life settings, short and long term effects of the natural environment, and the implications for management and policy of the natural environment. In this section we will elaborate on each of these parts.
WP 2 Methods:
Characterising the natural environment and the way it is used.
The research included evaluation of the natural environment, defined for the purposes of the project as:
▪ Green spaces (e.g. roof gardens, city parks, court yards) and “greenery”; forests, nature reserves/parks, mountains, farmland, trees, landscaping, etc.)
▪ Blue spaces; water such as canals, ponds, creeks, rivers, beaches etc.
Although many of these may actually not be ´´natural´´ since they have been man-made, for the purpose of the project we classify them as such.
One of the main aims of PHENOTYPE was to examine the importance of both quantitative (e.g. amount, type, access, use) and qualitative characteristics (e.g. acoustic quality, identity, variety, safety, rubbish) of the natural environment by collecting detailed data on these characteristics using a combination of methods. The focus lied on natural environments at different scales and distances from the home (city/town, neighbourhood, street level) and where possible also at other places where people stay (work, school, on their way to home/school, recreational). In addition, actual use of the natural environment was taken into consideration. To achieve the aim, a detailed assessment was conducted in four case cities (Barcelona, Spain; Doetinchem, the Netherlands; Kaunas, Lithuania; and Stoke-on-Trent, United Kingdom), with less detailed assessment in other study areas.
PHENOTYPE used conventional land use maps, remote sensing data from satellites and aerial photography, complemented by audits to derive comparable classifications of the natural environment in different countries. Collected data contributed to the characterisation of the natural environment (both quantitative and qualitative e.g. accessibility, acoustical quality, recreational activities, walkability etc). For the quantitative characterisation, PHENOTYPE made use of available land use maps such as COordination and INformation on the Environmental programme, initiated by the European Commission (CORINE) and Urban Atlas, and remote sensing and aerial photography to obtain comparable indices such as NDVI of the natural outdoor environment in different countries. Landsat Enhanced Thematic Mapper Plus (ETM+) data were applied to a classification and regression tree (CART) model to categorise land cover types for the urban areas of interest.
To collect additional qualitative information on the natural environment and on other physical and social features, systematic observations (audits) were conducted by trained researchers in selected neighbourhoods in the four case cities using the same methods. Since it was not feasible and not necessary to audit every street in a selected neighbourhood, a purposeful sample of streets was drawn, ensuring that important neighbourhood features were included. The selected neighbourhoods were divided into more or less homogeneous sub-areas by means of data/maps on land use/function of areas in combination with local knowledge of the area. Subsequently, trained auditors were asked to visit the sub-areas and observe them in a systematic way (auditing) using a paper form containing several close-ended questions. Every sub-area was visited by two auditors. For the first 1-2 areas, the auditors filled in the list together, discussing completion to reach consensus. In subsequent areas, where possible, the two auditors completed the audit independently and simultaneously. Furthermore, up to two natural environments of more than one hectare in size were selected per neighbourhood using GIS. Again following training in completion of the audit, two auditors visited the environments. For the first five areas, auditors undertook the interview together, discussing completion to reach consensus, thus maximizing consistency. In subsequent areas, where possible, two assessors completed the audit independently and simultaneously. In the absence of existing measures that met our requirements, the streetscape audit was developed for this project and the natural environment tool was adapted from an existing measure. Inter-rater reliability were estimated through derivation of Inter-rater Correlation Coefficients (ICC) and PCA used to ensure that any redundant items were removed and included items were grouped sensibly into domains, before overall quality scores was derived.
To investigate the mechanisms in relation to natural environments and health, a face-to-face questionnaire survey was conducted to collect data on around 1000 people in 30 selected neighbourhoods in each of the four case cities, and an in-depth study using “Calfit”, a smartphone-based monitor of time-location patterns and momentary states, on a subsample (n=100 in each of the four cities) of the participants of the questionnaire survey (for further detailed information, see next section on underlying mechanisms). The Calfit software ran on a Google Android operating system and as currently configured collected data on physical activity using the motion sensor and geographic location though a global positioning system (GPS), to obtain information on minutes spent and physical activity levels in different natural environments. Furthermore, in-depth interviews were conducted in 4 * 20 people who participated in the questionnaire survey and the smartphone study to investigate how and why people engage with the natural environment (green space and blue space). A qualitative methodology was used for that.
The work produced different indicators of natural space that can be used in the studies described below. We made a hierarchy of indicators with on the bottom simple measures such as NDVI that can be easily obtained in a comparable way for all the study areas and on the top detailed measures of for example green space with actually often local information on the quantity, quality and use that can only be obtained for only some areas after in-depth study. As part of the work, we examined the relationship between the simple and detailed measures to better understand how detailed information on small scale can help the interpretation of health studies conducted in larger areas with only simple measures available using existing epidemiological studies and registries (see below).
WP 2 Examining the underlying mechanism in the daily life setting
New data was collected to explore in detail and simultaneously the proposed mechanisms (physical activity, social contacts/cohesion, psychological restoration/stress reduction) underlying the relationship between the natural environment and health and well-being, in the four case cities (fig 2, Annex I). In each of these cities neighbourhoods varying in socio-economic status and in their distance to green space were selected. In these neighbourhoods the natural environment was characterised, and (as mentioned above already) we aimed for a selection of around 1000 randomly selected residents (almost 4000 in total, 18-75 years) participated in a questionnaire survey, 4 * 100 in a smartphone study, and 4 * 20 in in-depth interviews.
To optimally investigate what types of natural environments and different levels of accessibility are relevant in relation with the mechanisms that we investigated (physical activity, stress and restoration, and social interactions), and to investigate potential differences in this mechanism among different socio-economic population groups, we selected neighbourhoods with different socio-economic status (SES) and access to the natural environment. We used existing statistical or administrative units with existing statistical or administrative units that were as similar as possible with regard to variation in population size; in Stoke-on-Trent Lower Layer Super Output Areas (LSOAs), in Barcelona census areas, in Kaunas voting districts and in Doetinchem neighborhoods. Natural space and SES measures were assigned to all the units, using existing data. For natural space, Urban Atlas was used for Stoke-on-Trent, Barcelona and Kaunas. Since Urban Atlas was not available for Doetinchem, data of another Dutch database (‘Top10 nl’) was used. For SES no comparable data existed for the 4 cities. Therefore partners used their own local data. Then the units were ranked by each natural space and SES. Subsequently a selection of two neighbourhoods from each combination of top, middle and bottom tertiles of SES and quintiles of the natural space was made (approx. 2*3*5= 30 units). A few extra units were added to optimize contrast and reach a sufficient number of units to be able to recruit around a 1000 subjects in each city (30 subjects per units). Since there were no common person registries in these countries, subjects (aged between 18 and 75) were selected using different approaches. In Doetinchem and Stoke-on-Trent, addresses were sampled randomly from the BAG Registry (‘Buildings and Adresses’) 2012 and a local address registry respectively and the person with the closest birthday to the interview data was selected at each address, in Barcelona subjects were randomly selected from the person registry (empadronamiento) and in Kaunas subjects were sampled randomly from a 2006-2009 survey of randomly sampled people of the city of Kaunas. In each case there was an over selection of potential addresses or subjects to be able to interview at least a 1000 subjects (and 30 per unit) in each city. The target of a 1000 subjects per city was mostly based on the available budget. To enable multi-level analysis, we estimated that a minimum of 30 participants per group (or neighbourhood) were required, with a minimum of 30 groups.
The questionnaire survey was designed to investigate three potential mechanisms in relation to natural environments and health: via physical activity, stress and restoration and social interactions as described in the project Description of Work. In addition, questions were included about environmental worries and reactions to perceived exposures (air pollution, noise, etc). The choice of indicators was based on these three mechanisms and was achieved via an interactive process of experts within the PHENOTYPE team. As much as possible questions were derived from existing and validated indices, some tailored to the specific objectives of PHENOTYPE. The questionnaire was developed in English and was translated (and back translated) into Dutch, Spanish, Catalan, and Lithuanian. The questionnaire was developed to be applied in an oral interview of at maximum 60 minutes. In Kaunas it is not common to have face-to-face interviews; therefore a written questionnaire is sent by post to the selected people. The questionnaire was piloted by all partners, with specific attention for comprehensibility, clarity and duration and was adapted at some points based on outcomes of these pilots.
The final questionnaire was structured along four main clusters of questions: I. Green and Blue Spaces; II Residential situation: Dwelling & Neighbourhood; III Wellbeing and Health; IV Personal characteristics. For each mechanism are questions about availability, use, importance and satisfaction. In the sequencing of the questions we strove for a coherent set of questions per cluster moving from general to specific and from ‘’easy’’ to more intruding questions. Furthermore, most of the answer categories moved from neutral negative towards positive items. For all answers showcards were developed by RIVM, to make it easier for both interviewers and respondents, and to speed up the interview process. A separate instruction document was developed to train the interviewers. The questionnaire ended with an optional a pencil paper attention test (Color Trails Test (CTT-A)) (D’Elia et al).
Finally for the smartphone study at least 100 volunteers from each country were randomly selected from the participants of the questionnaire survey who indicated that they were willing to participate in the smartphone study. For these subjects, during seven subsequential days, the emotional state of the subject, the local environment (e.g. different quantities or qualities of natural space) and the social setting were assessed with the smartphone and the innovative Calfit technology. Besides objective geolocation and physical activity (see section Characterisation the natural environment), subjective data on stress reduction/restoration and social contacts were collected simultaneously. The latter data were collected through interactive diaries capable of eliciting ecological momentary assessment (EMA).
From the people who participated in both the questionnaire survey and the CALFIT study and who indicate they wanted to volunteer, 80 people (20 in each case city) were approached for semi structured interviews. These interviews were conducted to gain more detailed information on specific topics included in the questionnaire survey and CALFIT/EMA. Topics addressed included the motivation for travel routes, the associations of natural environment with mood, behaviour and well-being, the attitude towards and importance of (experiences with) natural environment, and reasons for using or not using the natural environment.
WP 2 Results
The research questions addressed were:
How can we explain the indications that close contact with nature brings benefits to human health and well-being?
1. What quantitative and qualitative characteristics of the natural environment are important?
2. How does the way people perceive the natural environment influence this association?
3. What is the effect of time spent in the natural environment?
4. Does it matter how important the natural environment is for people?
5. How do potential mechanisms interact?
6. Are there differences between subpopulations in these associations?
7. Does the context in which it takes place matter?
Main conclusions (methods)
There are several conclusions drawn on the used methodology:
• Combination of methods produced a rich set of data;
• Ambitious fieldwork;
• Innovative (e.g. smartphones);
Main conclusions (content)
• Having green and blue space in your surroundings is important for people;
• People spend most time in the natural environment nearby;
• More time spent in the natural environment is associated with higher mental health scores, higher frequency of social contacts and more physical exercise;
• The way people perceive the natural environment and the importance they attach to it for health-related activities (e.g. social activities, physical exercise) is stronger and more consistent associated than the quantitative characteristics of the natural environment;
• Perceived quality characteristics of natural environments (“variety in terms of plants and water”, “familiarity”, “colour” and “sound) seem to influence restoration of stress;
• If people visit a natural environment, then that is determined by a broad set of indicators, including their age, having young children, owning a dog, perceived quality and perceived quantity, a.o. things;
• For people with a low educational level, contact with nature may be more beneficial than for people with a higher educational level;
• There are clear differences between the four cities;
• In the densely populated city of Barcelona, there were some stronger effects than in the other greener cities;
• The mechanism is complex and should be considered in a wider (personal/physical/social/cultural & climate) context.
Take home messages
The conclusions have led to several general statements to be used by policy makers.
• Providing attractive and accessible natural environments nearby may improve health, in particular for specific groups such as the lower SES and in densely populated cities;
• Presence and size of the natural environment are not the only things that matter;
• Quality aspects are important as well;
• Taking into account the association between perception of the natural environment and health determinants, it is also important to know how people perceive the natural environment and why they use a natural environment or not from a health perspective; to create healthy designed natural environment, it is thus important to involve users of the natural environment.
• There are differences between cities, likely to be caused by local differences. Therefore creating healthy designed natural environment requires knowledge about the local context.
W3 Epidemiological studies to examine long term effects of the natural environment
WP3 methods
By using existing epidemiological studies and registries and linking these to the natural space indicators described earlier, the association between natural environment and a range of different long term health outcomes was examined in an efficient and cost effective manner. PHENOTYPE makes use of 16 existing cohorts and registries with good health outcome data in Spain, the Netherland, Lithuania, and United Kingdom, linking these to newly created natural environment indicators. Comparable estimates were produced for various regions in Europe for the associations with pregnancy outcomes, foetus development, children’s health and adult population morbidity and mortality.
Specifically focus was on:
▪ the natural outdoor environment and ethnicity, socio-economic status, women´s health and pregnancy outcomes;
▪ the natural outdoor environment and foetus development, birth weight, and gestational age;
▪ the natural outdoor environment and general development, neurodevelopment, cognitive function and respiratory health in children;
▪ the natural outdoor environment and respiratory health in children;
▪ the natural outdoor environment and obesity and sedentary behaviour in children
▪ the natural outdoor environment and general health, physical activity, specific morbidity and mortality.
The assessment of natural environment indicators was mainly based on satellite data and land use maps as CORINE and Urban atlas, and sometimes local data. This restricted to some extent the evaluation of the association with the natural environment, but this was the only realistic and achievable approach. All studies examined the role of socio-economic status, which was suggested as an effect modifier for the relationship between exposure to the natural environment and health benefits. Some cohorts such as the Born in Bradford study offered a unique opportunity to investigate the role of ethnicity in the relationship between exposure to the natural outdoor environment and health benefits, in Bradford study half of the participants are from Pakistani background, with information on both the mother and baby from pregnancy to early years in life.
Work package 3 studied birth outcomes related to access to natural spaces. Also children’s health effects were studied in relation to access by distance to green space. In adults, the effects on mental health were studied in relation to distance to parks or green spaces. Different mental health indicators were used in these studies like visit to specialists or the use of certain medication. In Lithuania more specifically the effects on cardiovascular health was studied in relation to access to green. Another specific study was the work on depressive symptoms in pregnant women in relation to distance to green.
Workpackage 3
Results and Conclusion
An increase in green space will lead to:
▪ Increases birth weight;
▪ Reduces mental health problems in adults/pregnant women;
▪ Improves cognitive function in children;
▪ Reduces behavioural problems in children;
▪ Reduces sedentary behaviour in children;
▪ Produces mix results for asthma in children;
▪ Reduces cardiovascular disease and mortality in adults;
▪ Reduces blood pressure in pregnant women.
In most of these studies people with low SES appear to benefit more. Furthermore, there is an indication that surrounding greenness is more beneficial than access.
An additional need for research has been discussed. The following needs were suggested:
▪ Longitudinal studies
▪ Intervention studies
▪ Contribution of various mechanisms
▪ More on where, when, how much, what type
▪ Quality assessments (e.g. audits)
WP 4 Methods Experiments to examine short term effects of the natural environment
To examine short term effects of the natural environment on health and well-being, one or more experimental studies were conducted in each country in which individuals were exposed to different types of natural and urban environments (i.e. environmental conditions). The majority of data collection was field-based to maximise the ecological (as well as internal) validity of any observed effects.
Using a range of psychological and physiological indicators relevant to the various possible mechanisms, and healthy and patient population groups (with mental and/or somatic morbidities) we collectively explored:
- Preventive and therapeutic effects of natural environments.
- Immediate and sustained changes in affective, cognitive and physiological responses indicative of well-being while engaged in a natural environment, and after leaving a natural environment
- Neurobiological responses to viewing natural or urban scenes before/after experiencing stress.
A randomised cross-over design, where possible, was used. Also a ccommon set of core indicators was applied. The protocol was standardized.Healthy unstressed adults, were to walk in non-stressful/pleasant urban areas vs. green vs. blue areas. The instorative effects were studied and that was done by single and repeated exposures.
Through variation in experimental design, each partner made a novel contribution(s) to areas as:
▪ UK: In healthy individuals, Study 1 compared immediate and post-exposure psycho-physiological effects of urban versus natural environments to explore whether any beneficial effects were sustained following single exposures; Study 2 used longer-term follow-up and repeated exposure to natural environments to explore whether any effects are accumulated, sustained or attenuated.
▪ Netherlands: an experimental functional Magnetic Resonance Imaging (fMRI) study was conducted in healthy individuals to investigate neurobiological responses to viewing natural or urban scenes before/after experiencing stress; i.e. whether viewing natural compared to urban scenery can prevent or buffer against stress responses, and how this was represented in brain activation patterns.
▪ Spain: in individuals with elevated stress levels, group-based exposure and Ecological Momentary Assessment (EMA, using CALFIT technology) were used to explore the role of social interaction and the nature of physical activity, in immediate and longer term responses. Ecological validity was enhanced through ‘free-living’ activities within environments, rather than controlling activities, again, using EMA, GPS and accelerometry to monitor the nature (and perceptions) of this activity.
▪ Lithuania: a clinical population with established coronary artery disease (CAD) was recruited to evaluate the therapeutic effect of the natural environment. The outcomes of this experiment had direct clinical applications for the use of urban and different types of natural environment in cardiac rehabilitation.
WP 4 Results
A higher perceived restoration in natural (blue and green) was found compared to urban environments at 30 minute follow-up (end of walk). There was no distinction between the walks with or without blue space included.
Improvements in cognitive functioning from baseline (lab) to 60 minute follow-up (lab) were seen in persons walking in natural environments (blue and green) compared to those walking in an urban environment. Their cognitive functioning returns to below baseline levels in the urban environment.
Main findings in the preventive studies:
In healthy, unstressed adults, light intensity walk in a natural environment confers greater benefit for perceived restoration and cognitive function; but pleasant urban and natural environment walks reduced stress and improved mood for all, over and above a healthy, unstressed baseline.
In healthy, unstressed adults, repeated light intensity walks in a natural environment conferred similar changes each day (not differentially attenuated or increased by environment).
Implications: Promote walking in nature during work day for sustained cognitive performance benefit. This is beneficial for employee behaviour and employer support. The general outcome is that a walk in any pleasant environment is able to reduce stress.
Main findings in the therapeutic studies (Spain):
In people with poor mental health, the exposure (three hours) to natural environment) improved their mood, and decreased stress levels and sympathetic nervous system functioning in comparison to exposure to urban environments.
The data also showed that restoration, physical activity, and air pollution are possible mediators.
Implications: Promote use of natural walks for those with mental health problems. Natural environments with blue space (water) can favourably affect the parasympathetic-sympathetic balance.
Main findings in the therapeutic studies (Lithuania):
The study was done with patients with a cardiovascular disease history of a heart attack. A park exposure vs. an urban environment benefits for additional benefits for blood pressure reduction, exercise capacity, heart rate recovery, mood (affect) and reductions in cortisol
Implications: To include natural environments in cardiac rehabilitation walking programmes for additional psychological and cardiovascular benefits.
Take home messages
The preventive studies lead to the following message:
‘If you take your lunch-time walk in non-stressful environment, you will have improved mood and reduced stress levels. But if you choose a natural environment, you should perform better at work after returning to your desk’
The therapeutic studies have the following messages:
‘Natural environments should be considered for inclusion in physical rehabilitation after CAD events, for additional benefits for blood pressure reduction, exercise capacity, heart rate recovery and stress levels’
‘Prolonged exposures in green and blue natural environments for people with poor mental health appear beneficial for mood, with beneficial stress reducing effects in green environments’.
WP 5 and 6 Methods and Results Implications, policy and guidelines and involvement of stakeholders
Guidelines
PHENOTYPE has provided recommendations for policymakers and guidelines for professional practitioners involved with spatial planning and health to create natural environments that promote health and well-being. For this, the project focused on a human ecological perspective which allows for a better integration of human health needs into land use planning and green space management in both rural and urban area. Legal standards that have been developed with economic, technological and political priorities in mind, are leading in urban design. Whereas the lifestyle, sense of community, identity, and health and well being of local populations have been largely undervalued. The guidelines reflected the importance to consider environmental, social, economic and other components of the natural and built environments in ways that also take into account and result from the point of view of citizens. PHENOTYPE complemented the common quantitative approach by valorising the social/human functions of these environments, especially their contribution to promoting health and quality of life.
The guidelines for professional practitioners involved with spatial planning and health considered three core topics in relation to each of the natural environment being considered:
1. Qualitative characteristics of natural environments; recommendations concerning surface area, vegetation, water sources, ambient noise levels, views and microclimate;
2. Facilities, Maintenance and Services; recommendations about the kinds of communal facilities and services provided in each type of natural environment, as well as suggested levels of maintenance;
3. Accessibility Guidelines to Natural Environments; including requirements about access to different types of natural environments such as allotments, neighbourhood parks, children's playgrounds and nature reserves.
The baseline for the work was firstly the compilation and analysis of currently available information from existing databases and literature, and later new data collected by the project as described above. This was complemented by the engagement with the appropriate stakeholders to assess scope for development. These insights were combined into a conceptual framework on the underlying mechanisms of the effects of the natural environment on health and well-being.
Stakeholders and dissemination
The participation provided a forum for project assurance and benefits for PHENOTYPE were summarised as follows:
▪ A more robust evidence base on links between exposure to natural outdoor environment and human health/well-being for various regions in Europe. Hereby we expect to develop a better understanding of the potential mechanisms.
▪ A better integration of human needs into land use planning and green space management in rural as well as urban areas. Furthermore, the application of these needs in practical guidelines.
Stakeholder involvement was critical for bringing outside (policy) ideas into the research planning, to increase the usefulness of the research, and to assure a better implementation of the results of the project.
From the start of PHENOTYPE actively sought to establish and maintain relations and dialogues with and between key stakeholders from local, regional and national health and environment authorities, institutions and the international research community. These included policy makers, architects, urban planners, natural space managers, health professionals, and the international research community. This group was highly diverse, as we were looking at a range of professions within the subject areas of environment and health, from volunteers to scientists, community workers and policy developers. PHENOTYPE has been successful in its engagement activities, providing continuous opportunities for information exchange and collaborations. These contributed to strengthening networking between researchers, policy-makers and stakeholders in order to facilitate the transfer of scientific knowledge to policy development, to exchange ideas about best practice and to help identify emerging issues on the natural outdoor environment and its mechanisms to improve health.
The PHENOTYPE website www.phenotype.eu provided and still provides an overview of the project, progress, actualities, surveys and publications. The site has a sign up form for newsletters and e-alerts through which all stakeholders are regularly informed. It guarantees continuous visibility, and provides a means for interested parties to respond to activities, or to contact us with invitations to attend workshops, etc. PHENOTYPE is also found on social media twitter @greenhealth4eu (300 followers), facebook (92 ‘likes’) and LinkedIn (60 members). The PHENOTYPE databases and overall results will be exploitable by reseachers and practioners at national and international level in areas including urban planning and health.
Method
Indicators, Guidelines and Recommendations
A number of core indicators were identified, both qualitative and quantitative, which may be helpful in a context of providing and monitoring of public green and blue natural spaces. Thirty-eight indicators related to nine categories of variable (described in detail in WP5 reports) play a role in the relations between public green and blue spaces and positive human health and well-being including:
• Indicators to assess the attractiveness of public green space to promote health promotion
• Multiscale analysis (street, neighbourhood, city, region).
The nine Categories of Key Variables are:
• Ownership
• Size/Shape
• Biological characteristics
• Functional uses
• Localisation
• Management
• Community and group identity
• Climate/Weather
• Nuisances
It was also found that:
A. Research confirms that the specific characteristics of public green spaces influence their attractiveness for individuals and population groups, but these characteristics are still not well understood. The definition of attractiveness is dependent on multiple factors including the specific culture of users as well as the bio-physical and geographical characteristics of public green spaces, and their intended use by individuals and groups.
Policy makers and professional practitioners should broaden their approach about the recommended size of public green space. There is no validated norm or standard for the size of public green space! Instead, PHENOTYPE has formulated nine key variables of the characteristics of public green spaces that define their attractiveness. These key variables are 1.) Ownership 2.) Size and shape 3.) Biological characteristics 4.) Functional uses 5.) Localisation 6.) Management 7.) Community identity 8.) Climate/weather 9.) Nuisances. These variables have been validated by stakeholders in both the public and private sectors in 4 European countries.
B. The PHENOTYPE study and other research show that the health benefits of access to green spaces varies between different population groups. For example, the health of women (pregnant or not), foetus, children, cardiac-patients and especially populations with relatively low socio-economic status, benefits more than other groups from access to public green spaces, residential proximity and uses of public green and blue spaces when these are localities for health promoting behaviours.
• Consequently, policy makers cannot avoid dealing with rights of access to and multiple uses of public green spaces for specific user groups, especially those with relatively low socio-economic status.
• The provision and maintenance of public green spaces involves political choices that have consequences for the promotion of public health. Beyond a common concern about the quantity of public green spaces in large urban areas, it is important to address social justice, such as issues of equity and fairness, especially those populations in residential neighbourhoods that do not live nearby these kinds of public spaces
C. The PHENOTYPE study and other research confirm that investments in the provision and the maintenance of public green spaces are also investments in public health. Public green spaces serve multiple functions, having co-benefits such as providing a cooling effect during periods of extreme heat; the absorption of storm water in case of prolonged rainfall or flash flooding; a retreat from relatively high ambient noise levels; and attractive localities for different kinds of health promoting behaviours (e.g. physical activity, children’s play, social interaction).
• Consequently, valuations of public green spaces should be requested by policy makers before they decide about the provision and maintenance of these spaces. The intrinsic value of these spaces, and especially those having high biodiversity, should not be equated with exchange values of land markets.
D. Research shows that the multiple uses of public green spaces highlight conflicts of interest between local residents, visitors, elected officials and civil servants especially concerning their rights and responsibilities. Public green spaces can be localities for small group or larger community meetings, recreational activities of members of local associations, or informal interaction between individuals. These spaces can also be sites for incivilities, drug trafficking or muggings.
• Therefore, appropriate landscape designs, management strategies and regular surveillance are necessary to prevent public green spaces becoming unattractive for health promoting behaviours.
• Alternative maintenance projects and management regimes founded on common property rights can enable local communities to maintain and manage these spaces.
E. Research shows that a lack of information and coordination between departments in local and national authorities concerned about land-use planning, green space management, transport and road infrastructure, social care and public health is not only common but also problematic and should be addressed.
• Consequently, intersectoral initiatives developed from a strategic and holistic vision, can provide a shared framework for the provision and maintenance of public green spaces that are attractive localities for healthy behaviours. This kind of initiative could begin with pilot projects in order to show the added value of intersectoral collaboration. Outcomes can only be effective if there is strong political commitment and sufficient resources.
• General practitioners should be interested in health promotion and prevention by diverse uses of public green and blue spaces. Doctors could attend public meetings about land use planning projects by local authorities in order to integrate health promotion into decision making processes. Public authorities should inform citizens about the health benefits of contact with public green and blue spaces.
F. Research shows that there is a lack of data and information about the characteristics of public green spaces in several European countries. Proxy measures are frequently used rather than measured variables in specific localities. This “missing information syndrome” is even greater with respect to the diversity of users, the multiple and diverse functions of public green and blue spaces, and the behaviour of residents and visitors in public green spaces.
• Consequently, there is an urgent need for policy makers and professionals to have access to reliable data and different kinds of information about the inherent characteristics and the multiple functions and uses of public green spaces. Systematic monitoring of these spaces is necessary.
• In addition to allocating public funds to fill this gap, citizen science could contribute to the collection and dissemination of data and information if local authorities and institutes of higher education and NGOs develop partnerships for their mutual benefits.
Overall conclusion
PHENOTYPE has addressed many of the shortcomings of the previous studies and has:
▪ Produced a more robust and comparable evidence base on links between exposure to natural outdoor environment and human health and well-being;
▪ Extended the evidence base to new outcomes and vulnerable populations e.g. pregnant women and their foetus, children, chronic respiratory and cardiovascular patients, ethnic minorities and low social economic class;
▪ Examined the proposed mechanisms (physical activity, stress, social contacts, and environmental risk factors) simultaneously in a large sample in various countries. This enabled us to study specific factors while adjusting for others, and thereby strengthening the interpretation of the results;
▪ Conducted comparable studies across Europe and produced evidence for North Western, Eastern and Southern Europe. This provided insights into regional, social and/or cultural differences in relation to natural space;
▪ Examined the effects of green space and also of blue space;
▪ Minimized the potential differences due to classification of natural space, by combining the use of conventional maps and data sources with remote sensing data and aerial photography and audit data, gather individual-level detailed data through of subjects living in the areas through questionnaire surveus, smartphones, and in-depth interviews and engaged stakeholders for further interpretation of data and discuss the implications of the research outcomes for planning and policy;
▪ Made classifications for the type and level of the indicators, which is important for policy makers;
▪ Examined the importance of both quantitative (amount, type, access, use) and qualitative characteristics (acoustic quality, identity, variety, safety) of the natural environment;
▪ Considered actual use of the natural environment, an often neglected but fundamental indicator in relation to exposure to natural environments.
▪ Considered the perception of the natural environment, also often neglected, but important to gain insight into what is important to people, and in how and why people use (or do not use) the natural environment.
▪ Robust field experiments have indicated that exposure to natural environments can provide acute therapeutic benefits for cardiac patients and those with poor mental health, and confers preventive cognitive benefits to healthy people which are not reduced on repeated visits.
The project has found that in general long term exposure to green space has a range of beneficial health effects including e.g. a reduction in cardiovascular disease, mental health problems, obesity and sedentary behaviour, blood pressure, an increase in birth weight, an improvement in cognitive function and behaviour in children and mixed results for asthma, which depended on the type of green space. Also short term exposure to green space has beneficial effects including for example an improvement of mood. In general, the exact amount and type of green space needed is still not fully clarified, but both access to green space and surrounding greenness may have beneficial effects depending on the underlying mechanisms. We found also that perception and use of green spaces are important in the observed effects. Exposure to green space is related to physical activity, social contacts and mental health, but the extent varies by country. The benefits of blue space on health were less clear. Policy makers and professional practitioners should encourage the presence of green space but broaden their approach about the recommended size of public green space. There is no validated norm or standard for the size of public green space. Instead, PHENOTYPE has formulated 9 key variables of the characteristics of public green spaces that define their attractiveness. These key variables are 1.) Ownership 2.) Size and shape 3.) Biological characteristics 4.) Functional uses 5.) Localisation 6.) Management 7.) Community identity 8.) Climate/weather 9.) Nuisances. These variables were validated by stakeholders in both the public and private sectors in 4 European countries.
Potential Impact:
PHENOTYPE set out produce more robust evidence base on links between exposure to natural outdoor environment and human health and well-being, and a better integration of human health needs into land use planning and green space management in rural as well as urban areas.
The project has delivered a wide range of results. These are produced in different formats: scientific reports; scientific articles; guidelines and recommendations for stakeholders or professional practitioners; stakeholder analysis and engagement plan.
Each of these formats have their own value in dissemination of the results of the project.
The results in PHENOTYPE have been produced in four work packages (WP). Each WP has produced its own reports with results, as well as articles in peer reviewed journals. There are different categories of stakeholder groups that are addressed in PHENOTYPE.
- General public: NGOs, Community Associations at different levels: national and local;
- Practitioners: urban and land-use planners; health promotion professionals; managers and designers of public green spaces.
These stakeholder groups have been identified within the consortium by the partners, in collaboration with stakeholders attending the different meetings within PHENOTYPE.
- Scientific reports: Results based on reports of the different WPs aim at scientists and policymakers. These reports have been or will be distributed by the work packages and disseminated via the PHENOTYPE website. Other stakeholders can also access these reports.
- Scientific articles: The scientific articles have been produced by the members in the PHENOTYPE consortium. Most articles have been published in peer reviewed journals. Some have been submitted. The abstracts of these articles are provided in Annex 1.
- Guidelines based on conceptual framework: WP5 has produced a report on guidelines for policymakers. These guidelines are linked to the results of this report. Professionals and practitioners, as mentioned above, might find these guidelines also very useful.
- General public: The general public has not been a prominent stakeholder so far for the consortium to disseminate the results, however, the partners have presented the project at public events throughout the project.
Throughout the project, partners have contributed to a significant number of (newspaper) interviews and video reports in the popular media. The general dissemination about the concept of the PHENOTYPE project to the general public has taken place in different countries. In addition, video messages were produced and disseminated via the project website (www.phenotype.eu).
Stakeholder interaction: The interaction with stakeholders outside the consortium has been analysed in PHENOTYPE Dissemination Strategy. Furthermore, the most favorable engagement with stakeholders has been described.
The results of the research of PHENOTYPE are important for different stakeholders. Results of research projects do have more value if they are translated into practical and understandable recommendations. This process is not always easy. Results from research always raise more questions. However, each result will point in a certain direction. If some health benefit can be added to a result out of the PHENOTYPE research it should be mentioned.
The presented results of the different studies within PHENOTYPE all have some value for implementation. Science produces a lot of results which can lead to more scientific questions. But there are always results that can be used to improve our world. Sometimes these results are still very indicative. Sometimes results are not causal to explain mechanisms. But always there are possible conclusions that cause no harm to take action upon.
A result can be descriptive and confirm common knowledge. There are some items that have been studied that are a proxy for a range of factors that cannot be described. For example, exposure to green in a park can stand for visual exposure, or exposure to odours, noise or temperature. If there is some positive health effect associated with exposure to green quite often we cannot determine any causal factor. Some exposure or characteristic factors (of natural space) provide an association with factors of effect without any causal relationship. There can be outcomes of interest (social or health effects) that may be influenced by factors related to natural space, but then there are also other factors related to the same outcomes. Another issue is the uncertainty about the representativeness of the exposed group. The results in some studies are not always making distinction between different subgroups such as socioeconomic, vulnerable or ethnic groups.
So, each result has to be merited for its own context of the study.
The results of the research of PHENOTYPE are important for different stakeholders. Results of research projects do have more value if they are translated into practical and understandable recommendations. This process is not always easy. Results from research always raise more questions. However, each result will point in a certain direction. If some health benefit can be added to a result out of the PHENOTYPE research it should be mentioned.
To enhance the potential impact of the project and improve dissemination at all levels, PHENOTYPE has released a clear set of recommendations. These are formulated based on the scientific field work and on literature analysis.
Field work
- The interconnections between exposure to natural outdoor environments, in both rural and urban settings
- Pregnant women have lower exposure to air pollution if they spend more time in greener surroundings. The location of residence and its exposure remains the same if this is not within 100 m of greenness. The effect might than be less. Greenness in residential areas seems to benefit pregnant women.
- Women that visit green areas, more specifically parks, show a beneficial effect on foetal growth. This effect is mostly seen in areas with low surrounding greenness. The implementation of more greenness or use of greenness in lower SES women seems to be beneficial on some fetal growth measures.
- When persons are near greenness general and mental health are better self-perceived and this is more consistent for surrounding greenness than for access to green spaces. This is also stronger for women and residents of non-densely populated areas.
- The association between the use of the park and residential proximity to the park revealed that women living more than 300 meters from a green space and who used the space more than 4 hours per week showed more depressive symptoms and poor and very poor perceived general health as compared to those who used the park less than 4 hours per week and residential proximity was more than 300 meters. This prevalence of depressive symptoms and poor and or very poor perceived general health was higher in women than in men.
- Less cardiovascular problems could be obtained by higher use of park and living nearer to green space. Public health policies aimed at promoting healthy lifestyles in urban settings could produce cardiovascular benefits.
- In women the probability of blood pressure increased by 9%, and that of high-normal blood pressure-by 14% for every 300 meters increase in the distance to green spaces. A beneficial impact of nearby city parks was seen on blood pressure amongst 20- to 45-year-old women.
- In line with these cardiac results it is seen that walking in a park had a greater positive effect on patients’ cardiac function than walking in an urban environment, suggesting that rehabilitation through walking in green environments after coronary events should be encouraged.
- Some inconclusive results show that more residential greenness was associated with worse mental health (more conditional problems and less prosocial behavior) in children whose mothers had a higher education level.
Underlying mechanisms
- The exposure related results do not provide any information on the underlying mechanisms.
- Residential surrounding greenness and subjective residential proximity to green spaces were associated with better self-perceived general health.
- Indications were found for mediation of these associations by reduced psychological distress and improved self-perceived social support and to less extend by enhanced physical activity. These mediators altogether could explain about half of the surrounding greenness association and one-third of the association for subjective proximity to green spaces. We observed suggestions that psychological distress and self-perceived social support might be more relevant for men and those younger than 65 years.
- The study on the association between visits to green space and mental health provides support for the hypothesized physical activity and social contacts mechanisms explaining the mental health benefits of visiting green space.
Effects for different population groups
- Positive results on the pre-born or born child is seen if their mothers make use of natural spaces during their pregnancy. This effect can differ in distance form residence to natural space or between with more or less greenness. There also seem to be differences between ethnic and socioeconomic groups in the city on better foetal growth. More beneficial effect in lowest socioeconomic group.
- The implementation of more greenness or use of greenness in lower SES women seems to be beneficial on some fetal growth measures.
- Children are another important group within the population. Findings support beneficial impacts of contact with green and blue spaces on behavioral development in schoolchildren. This supports the use of for more green/blue space play of schoolchildren.
- Greenness is good for reducing obesity and excessive screen time, be it residential surrounding greenness, forest or park. However, living near parks gives higher relative prevalence of current asthma.
- The study on determinants of visits to natural environments in the neighbourhood indicates which personal and environmental characteristics predict whether or not people visit neighbourhood nature. The identification of personal determinants reveals which people visit neighbourhood nature frequently and thereby which target groups need to be stimulated into visiting these environments more often. Equivalently, the identification of environmental determinants suggests which features of nature are worth investing in order to promote visits.
Effects of different characteristics of the natural outdoor environment
Quality characteristics of natural environments seem to influence restoration, therefore it is recommended to consider these characteristics when opting to design or improve natural environments which allow for restoration.
Preventive and therapeutic effects
- Several of the results mentioned above relate to preventive effects. For example those of the unborn child or perinatal effects. Also there seems to be an effect by living near greenness on reduction of number of children with obesity.
- Providing easy access to green spaces to enable people to visit green spaces, may be a promising potential public health strategy to protect and improve mental health, especially for people with a low level of education.
Implications for land-use planning and green space management
There are no clear specifically n land-use planning or green space management other than linking the results of the described sections above to those stakeholders related to land-use planning and green space management. The interest of insurance companies to link green space management to prevention of health effects is promising. The dissemination of the guidelines to stakeholders in the domains of land-use planning, green space management and additionally health insurance companies is recommended.
Guidelines
Work has been carried out to strengthen the conceptual framework of the health benefits of public natural space, which leads to guidelines. The implications of all of these findings for land-use planning and green space management are synthesized and transformed into guidelines. These guidelines consider three core topics in relation to each of natural environment being considered:
1. Qualitative characteristics of natural environments
(recommendations concerning surface area, vegetation, water sources, ambient noise
levels, views and microclimate);
2. Facilities, Maintenance and Services
(recommendations about the kinds of communal facilities and services provided in each
type of natural environment, as well as suggested levels of maintenance);
3. Accessibility Guidelines to Natural Environments
(including requirements about access to different types of natural environments such as
allotments, neighbourhood parks, children's playgrounds and nature reserves).
Where feasible the results of this work are incorporated in the implementation activities at each of the participating cities.
In so far results on these topics have been produced these will be used in the recommendations towards the implementation by the different stakeholders. This has been done in the workshops and final meeting with stakeholders. Furthermore, the consortium partners will use the compact format of the guidelines to further dissemination at a national level.
The results of the scientific filed work have been extracted from the different deliverables and the summary abstracts of the scientific papers. Most of these papers have been published.
The results have been discussed by the partners in the consortium and where possible with local or regional stakeholders in the participating countries.
The dissemination of scientific project results should have a prominent place in a large project. However, the larger the project, the more results are there to analyse, it is seen that it takes more time produce information to disseminate. Furthermore, results of scientific projects preferably are used for communication with different stakeholders.
The identification of sensitive persons (to new information on health and natural spaces) in different organisations was considered to be an important aspect of dissemination approach. Specifically for the topic of PHENOTYPE it is considered important to bring public health and urban planning together.
The recommendations of PHENOTYPE should be brought down to a more local level to become more practical. Moreover, a great opportunity is seen in bringing science, policy and practice together based on the PHENOTYPE results. To make the indicators valid for different cities one has to sit down with local authorities. There should be a link to monitoring these indicators. Architects have been mentioned as a missing link if evaluation of plans are considered.
These aspects of the work of PHENOTYPE are useful for exploitation in different cities. The outcome of the fieldwork is already been used in follow-up studies in other places or countries. For example, in the Netherlands the developed indicators will be used in a planned field study in three cities to compare different SES neighbourhoods on the impact of green on health. The socioeconomic health differences between neighbourhoods have to be reduced after this project. The results on social aspects of the PHENOTYPE project will be used in the implementation of the strategy to communicate with representatives of the different neighbourhoods.
Continuous work
Following the presentation of the PHENOTYPE results during the Final Stakeholder meeting in Brussels (December 2015), these have been taken into account for discussion during a workshop of the Institute European Environmental Policy (IEEP), addressing health and social benefits of nature to forge biodiversity protection. Our intention is to raise further awareness to the subject and contribute to further policy discussions, at regional, national and international level.
For example, in the Netherlands the results of PHENOTYPE have been discussed at a meeting of professionals of all the National Public Health Services, including a presentation. The outcome was to have factsheets on the policy implications of the conclusions on the results of PHENOTYPE. The results of PHENOTYPE are considered in a new tool being developed by the Province of Gelderland, the Netherlands, to support local communities in a quick scan on environmental issues in relation to spatial planning. The indicators developed by PHENOTYPE are considered for the green and health part of this tool.
In Stoke-on-Trent, one of the full-time PHENOTYPE researchers has go on to work within the City Council planning department with a remit to incorporate health into planning processes; e.g. ensuring Health Impact Assessments are completed and done so with sufficient rigor and regard for health-promoting aspects of neighborhood environments, such as natural environments. Some of the PHENTPYE data sources will also be linked with other health and local authority environment data to develop Health Urban Planning indices to aid planners and developers in maximizing health potential of future developments. This includes a new collaboration between the Staffordshire University team and the local hospital trust to explore environmental correlates of CVD risk factors using data from their Clinical Pathology lab. Finally, the University has established a new Centre for Health and Development (CHAD, www.chadresearch.co.uk); a collaboration between the Staffordshire University and local authorities. One of CHAD’s key thematic research area around Healthy and Sustainable Places and Communities, in which natural environments will be an important part.
The consortium partners are going to continue to produce more scientific articles based on the project results. Some of these articles have already submitted for peer review to scientific journals or will be submitted during 2016.
Contacts with other projects on green space and health offer further opportunities to disseminate PHENOTYPE results at meetings or conferences. Project partners intend to present at the International Society for Environmental Epidemiology (ISEE) 2016 in Rome, European Innovations Ecosystems Conference in Brussels, EU Green Week, INCHES (global network of people and organizations interested in promoting the protection of children from environmental and safety hazards) in Barcelona (September 2016) and at One Health / EcoHealth Brussels Workshop 2016. Conferences have also been attended during the official lifespan of the project to disseminate information and ongoings of the project as wide as possible (such as the annual ISEE conference), in particular to network with stakeholders and reach those with and interest and professional activity in policy steering environments.
The distribution of three PHENOTYPE documents could have a positive effect on putting green, natural spaces and health on the agenda of cities, or even countries. These documents would be in the format of a brochure:
- Guidelines
- Indicators (with addition of practical suggestions)
- Public health Implications
This is currently under development and will be disseminated starting in 2016, while final scientific papers are published.
Those publications which could not be entered in the NEF, but have been published, or are close to being published, are:
WP2:
1. Berg M van den, Poppel M van, Kamp I van, Ruijsbroek A, Triguero-Mas M, Gidlow C, Nieuwenhuijsen MJ, Gražulevičiene R, Mechelen W van, Kruize H, Maas J. Physical activity and loneliness mediate the association between time spent visiting green spaces and mental health: a multiple mediation analysis. (Under review, Journal of Public Health)
2. Ruijsbroek A, Droomers M, Kruize H, Gidlow C, Grazuleviciene R, Andrusaityte S, Maas J, Nieuwenhuijsen M, Triguero-Mas M, Masterson D, Ellis N, Hardyns W, Stronks K, Groenewegen P. Neighbourhood green space, social environment and mental health: an examination in four European cities. (Under review, European Journal of Public Health)
3. Ruijsbroek A, Droomers M, Kruize H, Gidlow C, Masterson D, Hurst G, Andrusaityte S, Nieuwenhuijsen MJ, Maas J, Hardyns W, Stronks K, Groenewegen PP. “Does the health impact of exposure to neighbourhood green space differ between population groups? A study in four European cities" has been successfully submitted online and is presently being given full consideration for publication in Journal of Epidemiology & Community Health.
4. Magdalena van den Berg. Physical activity and loneliness mediate the association between visits to green space and mental health: a multiple mediation analysis. (Under review, Public Health)
5. Magdalena van den Berg. Visiting green spaces mediate the associations between quantity of green spaces in the living environment and mental health. (In preparation)
WP3:
1. Magdalena van den Berg. Health benefits of green space in the living environment: a systematic review of observational studies. Urban Forestry & Urban Greening 14, 806–816. doi.org/10.1016/j.ufug.2015.07.008
2. Triguero-Mas M, Dadvand P, Cirach M, Martínez D, Medina A, Mompart A, Basagañ X, Gražulevičienė R, Nieuwenhuijsen MJ. Natural outdoor environments and mental and physical health: Relationships and mechanisms. Environment International. Volume 77, April 2015, Pages 35–41.
3. Gascon M, Triguero-Mas M, Martínez D, Dadvand P, Rojas-Rueda D, Plasència A, Nieuwenhuijsen M. Residential green spaces and mortality: A systematic review. Environ Int. 2015 Nov 2;86:60-67. doi: 10.1016/j.envint.2015.10.
4. Andrusaityte S, Grazuleviciene R, Kudzyte J, Bernotiene A, Dedele A, Nieuwenhuijsen MJ. Associations between Neighbourhood Greenness and Asthma in Preschool Children: a Case-control Kaunas Study. BMJ Open (Accepted for publication)
5. Balseviciene B, Sinkariova L, Grazuleviciene R, Andrusaityte S, Uzdanaviciute I, Dedele A, Nieuwenhuijsen MJ. Surrounding greenness, distance to city parks, park use and children mental health. Urban Forestry and Urban Greening. (Under review)
6. Gidlow CJ, Smith G, Wilson R, Trinder P, Martinez D, Grazuleviciene R, Nieuwenhuijsen MJ. Natural environments and cardiovascular prescribing in England. Landscape and Urban Planning. (Under review )
7. Stewart T. The natural outdoor environment and BMI in pregnant women in different regions in Europe. (Under review).
WP4:
1. Grazuleviciene et al. Effectiveness of a physical activity in urban natural environments on stress and cardiac function in coronary artery disease patients: a randomized trial. (Under review, BMC Cardiovascular Disorders).
2. Triguero Mas et al. The Effect of Different Types of Natural Outdoor Environments on People with Poor Mental Health in Catalonia. (Under review, PLOS ONE)
3. Jones et al. Psycho-physiological responses of repeated exposure to natural and urban environments. (In preparation, target journal - International Journal of Psychophysiology)
4. Hurst et al. A preliminary investigation into the mechanisms underlying the environment-health relationship: an image study. (In preparation, target journal – Journal of Environmental Psychology)
Dissemination materials will be also sent to the Network of the National Contact Points (NCPs) in Member States and Associated States. A news item regarding the PHENOTYPE recommendations will be submitted to the CORDIS database, and a press release will be prepared at CREAL and published coinciding with the publication of one of the main papers originating from WP2. This will also announce the completion of the project, and will be used to transmit a similar languages by the other Beneficiaries.
Meanwhile, the website www.phenotype.eu and the PHENOTYPE social media twitter (@greenhealth4eu), Facebook and LinkedIn, will continue to be active and function as reference sources and as tools for viral messaging.
Data originating from the PHENOTYPE project will be made available to Europe-based investigators at request, for which procedures are currently under development. In the long-run, exploitation of the PHENOTYPE results and the knowledge acquired during the PHENOTYPE project will be achieved via involvement of partners in other international projects, including those funded by the EU. Furthermore, the involvement of partners in policy networks at the national and international level, including different Directorates of the EU, Member States’ health ministries and their commissions, and regional health authorities, will facilitate the awareness of PHENOTYPE results and their possible use for the development and implementation of policies related to public health and environment.
List of Websites:
www.phenotype.eu
Diana van Gent
Project Manager
Centre de Recerca en Epidemiologia Ambiental
Parc Recerca Biomèdica de Barcelona
Doctor Aiguader, 88
08003 Barcelona, Spain
Email: dvangent@creal.cat
Tel: +34 932 14 7355
Fax: +34 932 14 7301